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HomeMy WebLinkAbout0067 BREZNER LANE - Health EEN RESNER RD. TERVILLE 230 143 : r IIII /J KEC Ctfpi �11�1I1� �� °^ z UPC 12534 �o IV0. 2-153LQR g�osr.coNs'�` HAMNQS, MN Commonwealth of Massachusetts W Title 5 Official Inspection Form ID Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Brezner Lane Property Address rQ John Conant r Owner Owner's Name information is `l required for every Centerville y MA 02632 8-7-17 page. City/Town State Zip Code Date of Inspecti 00 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms oZ� `��01%IIIIIIIIIF/, o on the computer, `� ESN OF M4S use only the tab `` - ' ..,. 1. Inspector: .- s key to move your CS N cursor-do not JAMES R, use the return James D.Sears =�: key. Name of Inspector Capewide Enterprises .. `�0:02 ICI Company Name 153 Commercial Street IN p�G,,,,,,ua"```� Company Address Mashpee MA 02649 Cltyfrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-8-17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /tl Vs f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is Centerville MA 02632 8-7-17 required for every page. Cityrrown State Zip Code Date.of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal Tank D Box and two chambers B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts G - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6" below invert or available volume is less than '/day flow 4,EAOov6 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is Centerville MA 02632 8-7-17 required for every page. CityrTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and two chamber's. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2015-135,000Gal g ( y g (gp ))' 2016-129,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Permit #2001 - 125 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 25" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H- 10 Sludge depth: 2" t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 15" below grade w/inlet cover at 6". In and outlet tee. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is Centerville MA 02632 8-7-17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16"-22" below grade w/one line out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 500 Gal. dry well chambers. Chambers are 27" below grade w/wet bottom. Wall's are clean like new. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 67 Brezner Lane Property Address John Conant Owner Owner's Name information is Centerville MA 02632 8-7-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately E AR CEMEut �,A7to � o 3 oa a,-e 13 s 33 N /3- 3 A G t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells jV0 Estimated depth to.high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger T.H. 12' no G.W.. Bottom of pit at 8' below grade. Bottom of pit at 4' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Brezner Lane Property Address John Conant Owner Owner's Name information is required for every Centerville MA 02632 8-7-17 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/19 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH'OF MASSACHUSETTS kiwiEXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 Bresner Lane Centerville, MA EEED Owner's Name: Mary DeRosa Owner's Address: 1Date of Inspection: — �7BLE Name of Inspector:(please print) Wi 11 i am E_ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: (5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: (/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:��1/ �,�.--�-- Date: 7-3-4 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaKh-or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approyng authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 Bresner Lane Centerville Owner: DeRosa Date of Inspection: :3—3—O-- 1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: k CT Zt/ B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. l Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exi Ping tank is replaced with a complying septic tank as approved by the Board of Health. * metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance in icating that the tank is less than 20 years old is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap oval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND xplain: The system required pumping more than 4 tunes a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N ain: Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 Bresner Lane Centerville Owner: DeRosa Date of Inspection: 3-3--8 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is f 'ling to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sy tem is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 Bresner Lane Centerville Owner: nPR n G a Date of Inspection: -3:-3—e5 / D. System Failure Criteria applicable to all systems:. u must indicate"yes'.'or"no"to each of the following for all inspections: Y No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool gg P Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well . f you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Br -liner T.ane Owner: T)PR r,c a Date of Inspection: Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No j�_ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ZHas the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? / 3 �, lr�Ij - V Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site c/ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b_affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. V— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Bresner Lane Centerville Owner: DeRosa Date of Inspection: 3 —3--0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no):2O Is laundry on a separate sewage system(yes or no):A d [if yes separate inspection required] Laundry system inspected(yes or no): 4 Seasonal use:(yes or no): !Li o Water meter readings, if available(last 2 years usage(gpd)): 2000 1 0 6, 0 0 0 gal. Sump pump(yes or no):/✓d 1999 101 ,000 gal. Last date of occupancy:. MERCIAL/INDUSTRIAL Typ of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Greas trap present(yes or no):— Indus ial waste holding tank present(yes or no):_ Non-s itary waste discharged to the Title 5 system(yes or no):_ Wate meter readings,if available: Last ate of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP�OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contact(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and sourceo information: Were sewage odors detected when arriving at the site(yes or no): 6 • Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Bresner Lane Centerville Owner: DeRo s a Date of Inspection: ILDING SEWER(locate on site plan) D pth below grade: terials of construction:_cast iron _40 PVC_other(explain): stance from private water supply well or suction line: omments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: r -10 14 16 G Sludge depth: p Distance from top of slud a to bottom of outlet tee or baffle: �1 Scum thickness: i Distance from top of scum to top of outlet tee or baffle: T Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): / � _J GRE E TRAP:_(locate on site plan) Depth low grade:_ Materia of construction:_concrete_metal_fiberglass_polyethylene_other (expla' ): Dimen ions: Scum hickness: Dis ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: C ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as r lated to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Bresner Lane Centerville Owner: Date of Inspection: T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) De th below grade: Ma rial of construction: concrete metal fiberglass__polyethylene other(explain): Di ensions: Cap cit} gallons De 'gn Flow: gallons/day Al present(yes or no): Al level: Alarm in working order(yes or no): D to of last pumping: C mments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: "✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PU P CHAMBER: (locate on site plan) Pu ps in working order(yes or no): arms in working order(yes or no): omments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Bresner Lane . Centerville Owner: DeRo s a Date of Inspection:7 —3—61 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: , overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): � —z �G Z ,L Is bG L CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): P (locate on site plan) M erials of construction: Di ensions: D pth of solids: omments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:67 Bresner Lane Centerville_ Owner: DeRosa Date of Inspection: -3-0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells ithin 100 feet.Locate where public water supply enters the building. l� l� � 10 NTi 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Bresner T.anP Centerville Owner. DeRosa Date of Inspection: 3-3-0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /3 feet Please indicate(check)all methods used to determine the high ground water elevation: 6btained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how yo established the high ground water elevation: LDS � �✓� � �`"�"� ;I w 11 j Z& ,/ "R77 ` per * No. G�{>/a' .4 � �7L '�U 4 Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS 0[ppricatton fort Migo0af 6p5tem Construction Permit Application for a Permit to Construct(,A'J Repair( )up,grade.( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 40 resn e/' I-O Owner's Name,Address and Tel.No. Assessor's Map/Parcel Z.?OP ,may Installer's Name Address,and Tel.No. 7 7� 77(o Designer's Name,Address and Tel.No. w.� ):?.VbOn.sOrr S2 P U CS da /a fr Q Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S,gay Nature of Repairs or Alterations(Answer when applicable)/A,Sf f/ 13`6 ZZ Z. dk, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir nmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bi oft ealth. J' Signed 4 , Date_-., Application Approved b i Date Application Disapproved for the following reasons Permit No. Ozg4rlr ;F-457 Date Issued K —r �BfS A4•n � `"' �e��i�' ,� / �l�v ra sgwe}er r j�1 1`i ."�, //�'v/, ref /kow";) y' yfy` No. f'� '' �� ✓ 6r� % ' /�y'��J,4�.O.Fc./ � <5 -®f/W� o. Fee � '✓ N / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ite• `.. 0ppfication for �Digooar 6petem Conotruction}Permit Application for a Permit to Construct(,,,\)/Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4p7 ,8reSn e e Ar7 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Y Installer's ame Address,and Tel;.No. 7-7 3 774. Designer's Name,Address and Tel.No. -"PoQda �oFrQ Type of Building: Dwelling No.of Bedrooms_{ t Lot Size sq.ft. Garbage Grinder( ) Other Type of Building - No. of Persons Showers( ) Cafeteria( ) Other Fixtures F , Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 Type of S.A.S. Description of Soil ', 4 .0 Nature of Repairs or Alterations(Answer when applicable)143-AI/ - a-r►d leQGLi St A ->-7/� x, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance Withlie provisions of Title 5 of the Envi nmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B-Dart of ealtl'. Signed Date Application Approved Date Application Disapproved for;the following-reasons Permit No. ;:7404J la Date Issued Job, Aa5,4 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed CA )Repaired ( )Upgraded( ) Abandoned( )by btJ at e 10 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit;Feo �dated !1 j Installer WAM 'e ah i n Se>7 S/L Designer The issuance of this ermit hall not be construed as a guarantee that the sy will function�Wesigf ed. Date Inspector ——————————————————————————————————————— No. G Q��� Feep'40 THE COMMONWEALTH OF MASSACHUSETTS t>-t 0�03,4 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwizpogar *p5tem Congtruction Permit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon( ) System located at,(�7 !J/`e S/i 11 r) �'d44 ry����-- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thispl9mut. Date: " �/ Approved b "v ' Ila" NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DLSPOSAL WORKS CONSTRUCTION PERMTr_ DESIGNED PLANS) L William E. Robinson,5%creby certify that the application for works construction permit signed by me dated '� "® � . concerning the property located at (p7 ;31Pe-SPe-k h 7ne; �P fyy>//e,meets all of the Mowing criteria: • The failed system is connected to a resider"dwelling only. There are no commercial or busium uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 3 u imu=per inch . Then arc no within 100 feet of the proposed static stistem — There arc no tivatc wells within l�l}teat of the proposed septic system There is no nevease in flow and/or change in use proposed Y There are variances requested or needed. • The bocce of the proposed leaching facility will Mt be located Ica than 5ve feet above the magi adjusted gmnndwa�table elevation.lAdjost the groundwater table using the Frimptor method hen applicable1 • If the S_a.S.will be located with 250 feet of any vemoated vim,the bomtua of the proposed leaching facility will 1a be located less than fourteen 1141 feet above the maximum adjured groundwater table elevation. Please eomplae the following: ?►) top of Ground Surbce Elevation(using GIS iaftmation) d B) G.W.Elevation _ +do MAX. ifigll G.W. AOntme It DIFFERENCE BETWEEN A and Bo SIGNED: ✓lJ G L �_./' DATE: [Sketch proposed plan of system on b K*I. -x haM folder:ccit �, '.-�. ' n ., s. 1 f 1 n ,� r r " DEROSA,MARY CONCETTA 101 MARY CONCETTA DEROSA TR " k15Io, 1 00001104 67 BREZNER LANE u % CENTERVILLE MA 02632 00-0000-000 a f F is�a 110189 k f DEROSA,MARY CONCETTA � � 1189 � , 6945/316 000031100 000082800 0000000000r, o "'67 BREZNER LANE 0176 0100 � D[s CO - -VW e 0000 0000 l � r A7— TOWN OF BARNSTABLE LOCATION reSvoe - LI SEWAGE # 7COI /;� VILLAGE v s I e ASSESSOR'S MAP & LOTZ3- all �� INSTALLER'S NAME&PHONE NO. '7 75-8-7'76 .SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �►Arnber5 (size) NO.OF BEDROOMS BUILDER OR OWNER A PERMIT DATE: 3- 2,01 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom df Leaching.Facility . Feet; Private Water Supply WelYand Leaching Facility (If-any Wells exist: on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facili ) Feet Furnished b, P [46 U .Tj. 7. (o-7 6rezner z-,iyw- + TOWN OF BARNSTABLE LO-ATION !3(" lNCC-` Lh SEWAGE # ;40I - gag .VILLAGE C.e n-4-e.r-y a Q ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.W-E A06(-n50✓) _7 7,5-8776 . SEPTIC TANK CAPACITY I JO0 a P 1 LEACHING FACILITY: (type) A CA A mb erS (size)�� 8 NO.OF BEDROOMS ) BUILDER OR OWNER 0e—rc6,A PERMUDATE: J"2,0 1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet ofleaching facili ) f Feet Furnished by Yf� k C3 P ' 1 f Y -I T +-4 0Pt� O .