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Home My WebLink About0051 BUCKSKIN PATH - Health 51 Buckskin Path Centerville P A _. 170 054 'I No. 42101/3 ORA r RD _ola_ 100 b�T/ t Commonwealth of Massachusetts 470' as Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cn 51 BUCKSKIN PATH M Property Address SANTOS Owner Owner's Name information is CENTERVILLE required for MA 02632 8-29-16 every page. City/Town State Zip Code Date of Inspection IV �A 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: A. General Information When filling out C/0 forms on the / computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 'BdOD City/Town State Zip Code 508-420-4534 S14297 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 8-29-16 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 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 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•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �a Ld VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owners Name information is required for CENTERVILLE MA 02632 8-29-16 every page. Cityrrown 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.): li ❑ 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 FIND(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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 51 BUCKSKIN PATH Property Address SANTOS Owner Owners Name information is required for CENTERVILLE MA 02632 8-29-16 every 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 cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 1 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. Cityrrown 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. El ® 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•3/13 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 , 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A 3 BEDROOM S.A.S OF INFILTRATORS THE ORIGINAL PIT IS ALSO STILL CONNECTED. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2014-------------287 2015---------248GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTLY OCCUPIED 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 z Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): I i General Information Pumping Records: Source of information: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: S.A.S INSTALLED IN 1997 FROM AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1.75 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 Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 51 BUCKSKIN PATH Property Address SANTOS Owner Owners Name information is required for CENTERVILLE MA 02632 8-29-16 every 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 Scum thickness LIGHT TO MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): IF THE TANK HAS NOT BEEN PUMPED IN THE LAST 3 YRS RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER FOR MAINTENANCE. 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•3/13 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 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM y 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every 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.): BOX WAS OPENED AND SHOWED NO SIGNS OF FAILURE BOX HAS 2 OUTLETS ONE TO OLD PIT AND ONE TO INFILTRATORS. 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: NO OBSERVATION PORTS FOUND ON INFILTRATORS. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 5 ' ® leaching chambers number: INFILTRATORS ❑ 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.): EXACT LEVEL OF WATER COULD NOT BE DETERMINED THERE WERE NO OBSERVATION PORTS MARKED ON THE AS-BUILT CARD. 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 t5ins-3/13 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 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. Cityfrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: NONE ENCOUNTERED AT PERCTEST 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: ATTACHED AS-BUILT CARD Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 51 BUCKSKIN PATH Property Address SANTOS Owner Owner's Name information is required for CENTERVILLE MA 02632 8-29-16 every page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ;. TOWN OF BARNSTABLE SEWAGE# D VILL:AGE�j►�w.7�.-��\�Q ASSESSOR'S MAP& INSTALLER'S NAME&PHONE NO. CIGJ SEP'IiC TANK CAPACITY f.LEACHING FACILITY: (size) 3f NO.OF BEDROOM 5 NT)C("eS BUILDER OR OWNER_ p � ,,�' ftA S �_ PERMITI)ATE: / [X �� co= MPLIANCE DATE: �l� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility moo; Feet Private Water Supply Well and Leaching Facility (If any wells exist A on site or within 200 feet of leaching facility) /11)C Fret- Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by AkuskLA a� X tkz Vat)( a C4 sr+ y� No. _1 F!0 Fee V14 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for 30i.5pogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(1)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel C'u�v 170 -- oZ. 1 3v LAk&K t, R C cw crv`l�s._ I taller's Name,Address, d Tel.No Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms J 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 Nature of Repairs or Alterations(Answer when applicable) VC,cs- c 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board Health. Signed Date �? Application Approved by t Date Application Disapproved for the following reasons Permit No. Date Issued �f vlrl No. Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,*1 PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfication for Mie;paal 6potem Construction Permit *Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. � Owner's Name,Address and Tel.No. �f QU�C.S v ` .�-e�--tSti C�tir s onS Assessor's Map/Parcel C�kry 7(� — 6 S S`J 13c,ckS Ki r, OS �- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. olC( PC�„n �c5 V / G,ni�M Type of Building: Dwelling No.of Bedrooms 3 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 Nature of Repairs or Alterations(Answer when applicable) c_ i A14 "nrVDM 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 Environmental Code and not to,place the system in operation until a Certifi- cate of Compliance has been issued by this Board ealth..Signed Date Zf/A 7 c Application Approved by Date Application Disapproved for the following reasons Permit No Date Issued 4 - - ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS t� Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired Upgraded( ) Abandoned( )by �cC�_��c 'CDb.s C CL^_S at C_ vl\\( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 1 Gr dated�Installer 1S n S&_�Si�-t A�.� CI Designer The issuance of this permit shall not be construed as a guarantee that the system will function as,designed. Date Inspector ---/ -- ------------------.--------- _-- No. 'Y Fee �IJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5po5a[ *pgtem on0truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 5 / f3 VC.1-C -,w n F.-rl� 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 this t. Date: �r ' Approved by � ✓ Q � ` 4 NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 4(k-:;g- (9 , concerning the { property located at �� yC�— ` meets all of the following criteria: i • There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility l There is no increase in flow and/or change in use proposed s There are no variances requested or needed. i SIGNED : DATE: LICENSE SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. °sl jxert y r �% i v �5� �./ ,. ,:. E 4k- .R� MAP r No...71-:2.2L / g2( r ` �3� . Fss.�....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE , ppliratiun for Diupuua1 Worko Cfuuutrttrtiutt Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................__- ........ ............_.....-- ..... - Location- ddress o No. `....... ''..:S Q_.L..........-^.................... ......�---1.....-_ .__•'•••-�?.1`�— --k -------.. .....--.. ..... CL Own r ` r� Address Installer Address Type of Building Size Lot----------------------------Sq. feet 4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons.....--..............------. Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.....--------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ 1 Test Pit No. I................minutes per inch Depth of Test Pit.--_---_---------.._ Depth to ground water......................... f4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water-.--___-----___,........ -- ------ - Descriptionof Soil �-� ..•------------------------•--•-------------------------------------------------------------------------....--------...---•• V •---•----------------•-••---••--------•-------•---•--------------•.._..-----------•------......-•----•--------------------•-•----------•------------------------•-••------------------------------------ UW ----•--------------------------------•••---------•--•--•------------------•-•------•-.....-----•---•-------------------------------- -- ff Nature of Repairs or Alterations—Answer wh applica -S_ _� ___________________� -_ �� l�� ------------------ -----e. ............. •--- ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com anc has e nissued by the board �of health. SigneSigned d ...... .... . 1........................` . ICJ ..L... Dare q Application Approved By ..... J----------------------------------------------------------------------- ---- -e Application Disapproved for the following reasons- ------- --------------- ---------------------- ---- -- -- ---- ------------------------------ ----------- -- --------- --------------------------------------------------------------------- --- -^-�...........------- ............. ......----............................. ----------------------------. ....------ ......................................... .....---------------- .------........ Permit No. ....... 1 '" . ./-------------_------.-.. Issued ........ Date i THE•COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ik atiun for Elhipao al Workii Tomitrur#iun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 3 I � ��t k, at.A 4-1- c7 /3 Location- ddress -• % Ow \ �{ Address ``' ---............................' .. .......................................................cj r S. . t.` ►'✓. �; ` V I fl e ,✓l� er . Installer Address d Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms ..................................Ex anion Attic— p ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -----------------.........-....................-.............. W Design Flow............................................gallons per person per day. Total daily flow....................._._______..............gallons. WSeptic Tank—Liquid capacity--------•...gallons Length-___-__-__.-_ Width_.............. Diameter---------------- Depth................ x Disposal Trench—No.0................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter--------------- Depth below inlet----•........-...... Total leaching area.....•.•..........sq. ft. Z Other Distribution box ( )' Dosing tank ( ) aPercolation Test Results Performed by------........-.........----............-..................•.............. Date---..............................•...... Test Pit No. 1................minutes per inch Depth of Test Pit............_____--- Depth to ground water.............•-......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil...... ............................................... V -------------------------------- ---------------- ------- ------ -------------- ---- -.---.---------------- -.------------------ ---------•---------------------------------------•---------••-----•------ W --•••-•...----- -----------------------------------------------------------------------------•--•-------------- •---•--------- r U --- Nature of Repairs or Alterations— nswer wh n applica � ' s �^ - < < 1 �l I a�. ---------------------------•--------------------------. ................0-0-0•-••-•••------------•------•--••-•--•-••----•-------• ........•................... ... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp tanc has been issued by the board of health. c / / Signed C4 Date Application Approved B '/ PP pp y ------- --- -------I-- ---- Application Disapproved for the follow reason,- ------------------ ------- --------------------------------------- . -------- ....--------- ......------------.------- ..... .. ................ .. ........ ......................... .. ................. .. .----------............--------------------- ---------------. ---------------------------------------- Date W ^ ^ ^ ! Date Permit No. .......c�l. .... � Issued ..../.-L-`--------------------- ------ ----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gextifirate of Tomyliance y THIS S 0 CERTIFY, That the,�ndividuaY Seg agY D C pos�l Sytem constructed ( ) or Repaired 1 d by..................... `._........ I....... ......._.__..........----..__._._...-----------------------------_Ins- I ...._.............;... r at ......... ------- -�............................................. e............................................................ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ............ ..r............. .. .._....... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE NR D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S�I FACTORY. DATE .. ?- •�-------------------�'........-------------------------------- Inspector . .......---.. .....................---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE........................ i pus a Vork.v (Tua try' n rrntit Permission is hereby grant ..........................0..................•............... ............................... to Construct ( ) �epair a a IrWdivi�rl�a t A' Di sal Sy hem v v; (ro atNo.................---•----------•- ---.........................--................................................--....................................... — J Street as shown on the application for Disposal Works Construction Permit No--- Dated.__.-------0.......................... J�a ------•-----•-••----------••------------------••--rd of Health DATE................ --------•-•-- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS ,f . •. TOWN OF BAR� A E �� . ( ° — LOCATION I �C�S�� r� CC SEWAGE # �� VILLAGE �[-�� .s (�. ASSESSOR'S MAP & LOT �3(� INSTALLER'S NAME & PHONE NOC C t�V3 �►CI�S. ��z� SEPTIC TANK CAPACITY I OG) Gf—SS @ o LEACHING FACILITY:(type) �— (size) /o 01) . NO. OF BEDROOM PRIVATE WELL OR PUBLIC WATER � h BUILDER OR OWNER rC'L O DATE PERMIT ISSUED: DATE .COLIPLIANCE ISSUED: lD ' 9.6 9 VARIANCE GRANTED: Yes No �. v . r a 1bob a ,, �. .► TOWN OF B.kRNSTABLE LOC',.110 `, ZQLUALk^_ SEWAGE # V VIf_'-AGI. s�A.�.-�a�� ASSESSOR'S MAP & LOT S d INSTALLER'S NAME&PHONE=NO. SCh C'- Vrtwk.Vk— WY-WIC SEP IC TANK CAPACITY t�+��--o EiC.L QAX /Ct LEACHING FACILrrY: (type) s (size) NO.OFBEDROOMS _ /1/711IC -CS ^C)- BUILDER OR OWNER PERMITDATE: IJ COMPLIANCE DATE: -7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist J�-�Q on site or within 200 feet of leaching facility) _��t Feet„ Edge of Wetland and Leaching Facility(If any wetlands exist -� v within 300 feet of leaching facility) Feet Furnished by ' A � Nk-0 ® v a cl TROY WILLIAMS - �z SEPTIC INSPECTIONS X0 Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETI'S EXECLITIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 'rinE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTF. EIVED PART A CERTIFICATION APR 17 2002 Propert% Address: 51 Buckskin Path Centerville,MA TOWN OF BARNSTABLE Owner's Name: Donald Parsons HEA TH DEPT. Owner's Address. 51 Buckskin Path Centerville,MA 02632 Date of Inspection: April 9,2002 O Name of Inspector: Troy M. Williams Company Name. Troy Williams Septic Inspections ? Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 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. 1 am a DEP appros ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The svItem Passes Conditionally Passes Needs further Evaluation by the Local Approving Author it) Fails Inspector's Signature: �� J,J Date: 'i/y/G z The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 ofTice of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the saute or different conditions of use. Title 5 Inspection Form 6/15/2000 Paee I Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 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 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to b eplaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board Health, will pass. Answer yes, no or not determined(Y,N,ND)in the_ for the following statements f"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(w her metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is ' minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by a Board of Health. •A metal septic tank will pass inspection if it is structurally sound of leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break ou r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o neven distribution box. System will pass inspection if(with approval of Board of Health): bro n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The system uired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection i with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 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. S)'stem Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)Wat the system is not functioning in a manner which will protect public health,safety and the enviro ent: 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 mars 2. System will fail unless the Board of Health(and Public Water S lier,if p any)determines that the system is functioning in a manner that protects the public health afety and environment: _ The system has a septic tank and soil absorption cyst (SAS)and the SAS is within 100 feet of a surface %%ater supple or tributary to a surface water su y. The system has a septic tank and SAS and e SAS is within a Zone 1 of a public water supply. The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". hod used to determine distance "This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatil rganic compounds indicates that the well is free from pollution from that facility and the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure triter' are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 Buckskin Path Centerville,MA Owner: Donald Parsons Date of Inspection: April 9,2002 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 cesspool is less than 6"below invert or available volume is less than 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. j�/,v 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. AIg 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 forma Nu (Yes/No)The system fails. 1 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 de ' n 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 criteri above) yes no the system is within 400 feet of a surface drinking ter supply the system is within 200 feet of a tributary to surface drinking water supply _ the system is located in a nitrogen sens' ve area(lnteiim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply we If you have answered"yes"to any ques ' n in Section E the system is considered a significant threat,or answered "yes"in Section D above the large sy em has failed.The owner or operator of any large system considered a significant threat under Section E failed corder Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner sho contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 Check if the following have been done. You must indicate'yes"or"no"as to each of the following: Yes No _ information was provided by the owner. occupant,or Board of I icaltl, 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 Nvith 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. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 Buckskin Path Owner: Centerville,MA Date of inspection: Donald Parsons April 9,2002 FLOW CONDITIONS RESIDENTIAL 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): 3 3 0 Number of current residents: 3+..S Does residence have a garbage grinder(yes or no): 10 Is laundry on a separate sewage system (yes or no):N"._ (if yes separate inspection required] Laundry system inspected(yes or no):�q Seasonal use:(yes or no): A/o Water meter readings,if available(last 2 yearsltsage(gpd)): 0 t = 9 7 ooV � ��.,, oo = �4,�o u 5�.u,H S. Sump pump(yes or no): Ato Last date of occupancy: ,, a. COMM ERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):- Non-sanitary waste discharged to the Title 5 syste yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A/o Was system pumped as part of the inspection(yes or no): Aio If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM vl 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) Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components. date installed(if known)and source of information: 0-l30. o' =T..vit 41,- +v- i t,- .. z 1i a -A o. X/6 c$2 Were sewage odors detected when arriving at the site(yes or no): A'U 6 Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 ' BUILDING SEWER(locate on site plan) Depth belu�% grade: /9" 1 Materials of construction: _cast iron ,/40 PVC_other(explain): Dktancv fron. pri%ate water supply well or suction line: '�J/'4 Comments(on condition of joints,venting, evidence of leakage,etc.): (_t,,y1�.�� 1 . .5 .�✓ �J'W' C.I cc.✓ ,+ti h SEPTIC TANK: ✓ (locate on site plan) Depth below grade: I 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: 6 s 'x iy.s x C /.you Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: a2 Scum thickness: It (may-- Distance from top of scum to top of outlet tee or baffle: _6_ Distance from bottom of scum to bottom of outlet tee or baffle: i 4e!' How were dimensions determined: Pr t.. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass po ethylene_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 baffle: Date of last pumping: Comments(on pumping recommendations,inle d outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaka ,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of ection)(locate on site plan) Depth below grade: Material of construction: concrete metal fibergla _polyethylene other(explain): Dimensions: Capacity: gallons Design Flo% . gallons/day Alarm present(yes or no): Alarm level: Alarm in working ord (yes or no): Date of last pumping: Comments(condition of alarm and flo switches,etc.): DISTRIBUTION BOX:-V-/—(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: t I Comments(note if box is level and distribution to outlets equal,any evidence of solids carrygver, any evidence of leakage into or out of box,etc.): p / .l l G✓ w c c.✓a ( t f'r 4b U f"7 u l O/ r) v1 c G_ �i o a. . s.�c �l }0 1 u TO•'h.�c s.+ `-h K^c PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,cond' ' n of pumps and appurtenances,etc.): 8 Page 9 of l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons April 9,2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: I - y 'x L<k ,� + 2 "S},,, . leaching chambers,number: S - 1 + �s;, rl `I s+-U-� 4— --A 4_ /'y 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.): O� I l.J u. �_. l_ca c-�... c. ..,J� S u=� /«nD t.i.'�.l g..� � � f�-n.J7✓n. I'. � � �� ti Lc � c1r7 Sa .c >lc CESSPOOLS: (cesspool mustZfailu"re, inspection)(1 to on site plan) Number and configuration: ---- -- Depth-top of liquid to inlet invert:Depth of solids layer: Depth of scum layer:Dimensions ofcesspool: Materials of construction: Indication of groundwater inflow(yeComments(note condition of soil,si , 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 hydrauli ailure, level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Buckskin Path Centerville,MA Owner: Donald Parsons Date of Inspection: April 9,2002 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 within 100 feet. Locate where public water supply enters the building. A A 0 30,� ' �SOu�l4tl�� A r - 38' D 0 , L17.Y Fw •t O F 32 ' C_ F ` 571 6 � 30, 9 F 4'X/6 /l S h1 f—'1 l-rro.4v'-, W--41, S�-prn. �.IS�-v,...� Pvw..J1 P✓�� y�Uw�C� 0 Page l l of I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Buckskin Path Owner: Centerville,MA Date of Inspection: Donald Parsons SITE EXAM April 9,2002 Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water 21• ' feet Adjusted high ground water elevation feet Please indicate(check)all methods used to determine the high ground %%ater elevation: Obtained 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) �.L Accessed USGS database-explain: S L?w z s z 2�,�,� u s- .4�1 yv You must describe how you established the high ground water elevation: i)Cc. s �,�„�.,� �.,� �.., �,.. � �1=4_ tip..•_ ►- i. �.r,_ ys. � ' G .� ,� } 1, ..o.a ram. 1 t( . G G O U G /o L G O O G ri G 11