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HomeMy WebLinkAbout0110 BUCKSKIN PATH - Health 110 BUCKSKIN PATH, CENTERVILLE A=170-011 ��/�� /J J�RECYCIfp�O UPC'12534 Nv.2-15r 3LOR HASTINGS,MN � 1 f► 4 No. G'�J am' LCl `� Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for -Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. t Owner's Name,Address,and Tel.No. uCkS�'^n Assessor's Map/Parcel '� C s {+� CoKA.) q e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. SC6 -a -3 "96 pr 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(min.required) ' gpd Design flow provided gpd 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) P��CCd.C� '�c'l�C ��L— i Date last inspected: Agreement: The undersigned agrees to ensure the construction and main ance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir ental e d oft place the system in operation until a Certificate of Compliance has been issued by this Board of Heal e Date Application Approved by Date ?,o t Application Disapproved b Date for the following reasons Permit No. ZDI G ' 7 j y Date Issued 3 , No. (DIG — !` RR�y� Fee / J. t - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for MisposaY *pstem (Construction Permit Application for a Permit to Construct( ) Repair^ Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. T�,jCkSJZ r11 . Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel -� _ �� ?Ile" CIrA., `Same Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Cfa2+.n;�.J SuAY Sob -294- 9& A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) I Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _�* gpd Design flow provided 6 gpd Plan Date Number of sheets Revision Date Title ' Size of Septic Tank Type of S.A.S. Description of Soil .� q Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction annd maint ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir kfinental e d t t place the system in operation until a Certificate of Compliance has been issued by this Board oAlt S.gn Date - 4 Application Approved by i Date -Z 3 ?m/(p Application Disapproved b 1 Date I 1 for the following reasons Permit No. Date Issued ----------------------------------------------- '-�------------------------------------------------------------------------If-- 'r THE COMMONWEALTH OF MASSACHUSETTS �^ BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k) Upgraded Abandoned( )by at o %,N has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0010'Z 19 dated 61z3/-n,i b Installer p Designer #bedrooms 0 Approved design flow gpd The issuance of this[erit shall not be construed as a guarantee that the system will tintio�n designed.Date U Inspector f l P ------------------------------------------------------------------------------------------------------------------------------------ - No. 0�1 ��� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS f Disposal *pstem Construction Permit 04L`tJ Permission is hereby granted to Construct( ) Repair(XQ Upgrade( ) Abandon( ) System located at �J`lthcs� and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. Date Approved by —�� AsBuilt Page 1 of 1 TOWN OF B TABLE t LOCATIO SN� C- �~' SEWAGE M /14 VII LAG ASSESSOR'S MAP&LOTD� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 of leaching facility) Feet Furnished by �tti� III D-eCk a pC AC u3 � qo �b 2b R� b j http://issgl2/intranet/propdata/prebuilt.aspx?mappar=170011&seq=1 7/6/2016 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C M 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name c? information is 3> required for every Barnstable Ma. 02632 July 15,2016 F=,. page. Cityrrown State Zip Code Date of Inspection t-+ M2 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 l- filling out forms on the computer, �` �--"r use only the tab 1. Inspector: key to move your cursor-do not Thomas Roux use the return Name of Inspector key. — - 1 Company Name 89 Mayflower Lane Company Address 1 East Wareham Ma. 02538 City/Town State Zip Code 774-678-9066 S14531 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 S / Inspector'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 L41e�,� 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 A O/ow rS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every Y page. City/Town 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: ® 1 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: 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 �M 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every y page. City/Town 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•3M 3 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 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 July 15 2016 required for 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 July 15 2016 required for 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �., 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every y page. City/Town 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): 548 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Jan. 2016 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-3/13 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 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 ,Jul 15, 2016 required for every y 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: owner 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) (f 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 21 years, From the design plan on file. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.1' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.1' 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: 8'L x 5.2'W x 5.TH Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Swvage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15,2016 required for every y page. Cityfrown 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 30" Scum thickness <1" 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 16" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped out at this time. 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 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every Y 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-3113 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 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 July 15 2016 required for every > page. City/Town 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.): The D-Box is in very good condition with a riser and the cover is to within 3"of finished grade. 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: The septic tank and D-Box are functioning correctly. Therefore,the SAS is functioning correctly. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15 2016 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 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.): No evidence of hydraulic failure. 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 Forth: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 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15, 2016 required for every Y page. Citylrown 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.): I� t5ins-3113 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 U 110 Buckskin Path Property Address Ellen Carty Owner Owner's(dame information is Barnstable Ma. 02632 Jul 15 2016 required for every Y page. Cityrrowm State Zip Code [We 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 S _ 3q 47 �6. t5ins•3113 Title 5 Offi tal bispedw Forth: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 M 110 Buckskin Path Property Address Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 ,Jul 15 2016 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cent.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: below 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. 3/2195Date ❑ 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: From the design plan on file. 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 s 110 Buckskin Path Property Addreas Ellen Carty Owner Owner's Name information is Barnstable Ma. 02632 Jul 15, 2016 required for every Y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checkllsb ® 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•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Catty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. Cdyrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be althred in any way.Please see completeness checklist at the end of the form Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections raa Company Name P.O.Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 8 � ; 508-385-7608 S13742 ark E,� Telephone Number License Number _ _ 4 B. Certification C rl U_ . - t�­ I cerlify 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. Iam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority &4el 2- t56�= 12/05/11 Inspe ors 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•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 a f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. City/Town state Zip Code Date of inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: 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) Mrs-11/10 Title 6 Official Inspection Form:Subsurface Sewage.Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. City/rown state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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. Or 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-11/10 Title 5Official 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 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03111 page. c4frown State Zip Code Date of Inspection B. Certification (coot.) 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 501 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 Cl ® 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'1 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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. e9 P t5ins-11110 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owners Name information is Centerville MA 02632 12/03/11' required for every page. Cityfrown state Zip Code Date of rrtspection 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 Sod 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 1.5.302(5)] D. System information Residential Flow Conditions:. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 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 110 Buckskin Path Property Address Ellen Carty Codry Owner Owners Name information is required for every Centerville MA 02632 12/03/11' page, Cityrrown state Zip Code Date of 1'nspedibn D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required], ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings,if available(last2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial Flow Conditions: Type of Establishment:. Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/personslsq.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: sirs•";f D Title-5 Official irspeedion Form:Subsurfacce Sewage Dispmai S,item•Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. Citylrown 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: 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Cl Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Flame information is Centerville MA 02632 12/03/11 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components,date installed(d known)and source of information: 03/20/95 per BOH - Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer{locate on site plan): Depth below grade: 1.9 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: 1.3 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: 1000 gal 3" Sludge depth: t5ins-11110 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 110 Buckskin Path Property Address Ellen Carty Codry Owner Ownees Name information is required for every Centerville MA 02632 12/03/11 page. C Wrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29` Scum thickness 2" 9„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 141" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and fight with tees in place and liquid at outlet invert 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 �'" •""^ Ttt1E 5 v'Alai Mspecton ,"1:Subsuftce Sewage Disposat 9isttm•Page i4 ot',T Commonwealth of Massachusetts ua Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. Citylrown 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: Dace Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is Centerville MA 02632 12/03/11 required for every page. Cityrrown state Zip Code Date of inspection D. System Information (cont.) Distribution Box(f present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.):. The box was level and tight with no sign of carryover. 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. City/rown State Zip Code Date of inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number. ❑ leaching galleries number: Cl leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/aitemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has 6)Q'precast pit surrounded by 2'of stone .The pit had l'of liquid with a stain at 6" up. 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-f Y/10 i Ne 5 Grirciai inspection Form:Subsurface Sewage Disposai System•Rage is of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. CityrTown state Zip Code Date of Inspection D. System Information (cunt.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L_ Commonweafth of Massachusetts Tide 5 Official inspection Form Subsurface Sange Disposal SYSIOn FOnn-Not for Voluntary Assessments 11.0 Bucksldn Path propedy Address Ellen CadY Cod owner owner's Nesne 12103/11 information is Centerville MA 02 regtdred for every aiiifa—wn Smote Zip Code Dab of tnspeewn page. D. System information (cant.) Sketch of Sewage Disposal System:Provide a view of the sewage disposal systern including ties to at leasttwo permanent reference landmarks or benchmarks-Locate all welts within 100 feet.Locate where public water supply enters the butftdmg.Check one of the boxes below- ® hand4wtch in the area below ❑ drawing attached separately 3, ' a� 47 6 To.5 Opal mepeCtloe f_:SSC�AeW Sgwrage P4_0 gym'F"e it of 17 ems•»no Commonwealth of Massachusetts Title 5 Official Inspection 'Form s Subsurface Sewage Disposat System,Form-Not for Voluntary Assessments 110 Buckskin Path Property Address. Ellen Carty Codry Owner Owner's Name information is Centerville MA 02632 12/03/11 required for 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. 20.0 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: USGS maps show an elevation of over 20.0 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Buckskin Path Property Address Ellen Carty Codry Owner Owner's Name information is required for every Centerville MA 02632 12/03/11 page. CityrTown 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 t5lns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BAR TABLE LOCATION G EWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER 4-7Q PERMITDATE: 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 of leaching facility) Feet Furnished by iy act(- IA c At'No.....9.0 Fmc ® �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH bl TOWN OF BARNSTABLE 1� plirtttion for Biopoottl orko nwitrnrtion ramit Application is hereby made for a Permit to Con ( ) or 1t t ( ) a >vr Sewage Disposal System at: .�- !'fin ,J'� 14/ ..._ wtion-,V 4 , J or Lot No. Owner Address W : Installer Address — dType of Building Size Lot.............4- '. .Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.................._--------- Showers ( ) — Cafeteria ( ) a' Other fixture ._. _ ... W Design Flow......................... ............gallons per person per day. Total daily flow........................... _:5,0.....gallons. WSeptic Tank—Liquid capacityl gallons Length________________ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area.......... sq. ft. o Seepage Pit N .-._--------I-._ meter.........i0---- Depth below inlet-_,..... ....... Total leaching area...... q. ft. Z Other Distribution box ( Doying �( ) //y // /g�¢� a Percolation Test Results Performed b Xr��¢(✓ . lam. 6N�._._...__._ Date................. . . 0 Test Pit No. I......Z,_minutes per inch Depth of Test Pit----- Depth to ground water-_---- ..-. Gz, Test Pit No. 2................minutes per inch Dk�th of Test Pit.................... Depth to ground water............___.._..___. -•--•-------------- �' - Description of Soil----------------------Q :/ ......... ' ---------..-- ---------- ----- ------ -------------•--'---------- W �f•L-•--------•-•-•rff ....iS---- ----•---------------••------------------------------•------------------.....-------- x ----••-----------------------------------•--•-•-•-••-----------------------------------•------•----------------•------------------------------------------------------------------------•-•-•----------- U Nature of Repairs or Alterations—Answer when applicable...--........................................................................................... 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 Compliance has been issued by the board of health. Signed ............. 0 ............. .. Application Approved By ---- . -- ..-�.--- - ---------------------------- Application Disapproved for the following rear n - ------------------------'`- ------------------------------------------ . .............................. ...... . .......... - ---------------------------------------------- -- ................ .��..�,� ----- �.........- - Issued ..... Da e Permit No. ...... Da No....`�t. Fxs.....1........ ft THE COMMONWEALTH OF MASSACHUSETTS ;,. BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Cnoustrnrtinn lirrmit Application is hereby made for a Permit to Construct ( ) or Repair.( ) an Individual Sewage Disposal System at ............. .............. '-' Location- ress or Lot No. L....lJ-----.--...........G ---------•----.----• -------•-•-----------------------••---......--------------....-----....---------•.......•-----.--- Owner Address W Installer Address L7 0,�� d Type of Building Size Lot.............{..._...)..Sq. feet Dwelling=' No. of Bedrooms---------------------------------------- ---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixture-- --------------------------------------------------------------------------------------- ---------------------------------------------•--•---•-•.----. W Design Flow./.....................� ............gallons per person per day. Total daily flow---------------------------...3_O.....gallons. WSeptic Tank—Liquid capacity aJL)_gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage,Pit No...........L...._. meter......... v__-. Depth below inlet---------�....... Total leaching area......�_��._Asq. ft. Z Other Distribution box (� Dosing to ( ) / 0 '~ Percolation Test Results Performed baXr ____?�.1/._k!`--__-1Y<—.......... Date........ Test Pit No. 1.---.--Z -__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_...---.-__-____---__--. x ----- ------. Description of Soil----------------------- .......4 S---�-CL W ------------------------------------------------------•••------•----------.----- V ....•-•-•-••-•----•--------------•---.....-------------- ....-- W 1i')---- ��-----;------------------------------------------------------------------------------------ x --- ------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ •--------------------------------------••----------•--•----•-----------------•--•-.........•--------------------------------------------------•---------------------------------------•-........-------- 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 Compliance has been issued by the board of health. / Signed --------z7)------------A -- >.....- Application Approved By ... _./..........?:._'...:- ... —, 9 l ! , I i�. Application Disapproved for the followi�ngj/�reaso�- --------------------------------------------------------------------------J././.jI...................... ----..........................................—.. '.--- / ----— --- ---- t ----------------------------------------------------------------------------------'------/__. __ �� Dare ............ Permit No. .`1.,... ....... . -- Issued ` ...:. ----------------- 1 ....... L�j Date--....i 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Te>r#tftra e of Tomplian e THIS IS -0 CERTIFY, That the Individual Sewage Disposal System constructed ( L- ) or Repaired ( ) by ... ..----- Insc il" at ..... G/L,S, %/ ✓�- - �../�/r--IJ,S f------------- =�v--------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State E vironmental Code as described in the application for Disposal Works Construction Permit No. ... ........._..._.. {� .......... dated . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 9ttONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- -- - ....'., _... Inspector � - THE COMMONWEALTH OF MASSACHUSETTS (� BOARD OF HEALTH TOWN OF BARNSTABLE No.q,:r FEE....].................. 1 Disposal Works Tunutrutiun Wrmit Permissionis reby granted-------- ----------- ------------------------- ----------------------------------------------------------------------------------------•----- to Construct ( or Repair ( ) an Individual Sewage Disposal System at No. 1/G/Lj/,1 - 1'tr .._... U -------------� ----- - ----- - - --- --- Street j as shown on the application for Disposal Works Construction Permit No .. .j_:____._ ated____��?..is 6.:! 1 ...... � �I . � /�_ C�'/ Board of Health DATE.................... ------ •--•-• (( [� FORM 36508 HOBBS✓k WARREN.INC..PUBLISHERS ,P' "P,ATA IQ FAMILY 3 $E7.'> Mj' S'T'?�t��`� c'—"c-IF7: `'n4t.2 :- AILS( FLOW 3X I10=3 13v pp QA'`°00, — -- -- - uq•� . . SEPT'l C TAIJ�3�X I So vf�°�1�6►� � % 8 .� �LSPoSAL PIT (-Invv�nc. �zSrON� I Vale 1/1 m SIDEW4U- Awc-A =10f, 'sF T°P°F 1 . .'_ I8� SF X �.�S =•4'1a �Pv, � � Pi-apose�! � a� I BOTTOM A _ '7 0 sr- MIN TOTAL 'DAILY rLOW�=� 3?0!p©;,0v PEP�aLAT1oN ATE Fe°' FfroP ' 1 a^• n� vim.. A-,`t LA? %A, OF /L:�� ��`'��' - � PETER �� � I 'SS m / '�' • cr i, g SULLIYAN Nu.24a,.� No. 29733 loti `�1— �.>_ 73 I Q.e-- I �l.`�Ioo �(.= lal•S - r(iz I°( TF=1a2 SJ6501L P V.C. " CLAY d- D1ST ►uI Iw GAL llQV 8 99 �'S I ovo cur I►N E;CK qsa 4eprIC GAL 9 TANL t rer. . WI TJA/Z, `. wmge;, . �vit: A►�5ntucruQEs s�T sToNE MOW TUAI-i 4' vEE-P Si-(AcL 'BE I-F-Zo n/ P I`1O I%4-Zr-G=L lI �y11-oP 'Pr�vFl c E-- SL C�i'►�l m P�.�' FLA N . 'f IT LE-, DATE-; MAP. 2, Iqq S 2E�E l CEZTIFy 744AT T4S 'bi,c)r=GU0� QLA N RFJJC,� S!{owtJ NE'ZE1�N COMFL S WITµ TAS 51'DEL Wp 7-aQ, pt TI(E TDA OF 73AAZ N`i rAwL-9 R. 3,Z415 p SSlo+Jd1_ LA►J� 5up-ve Cc 'rgl► FLA�i lS Ncr «3A�,1:J oN AN I�JSTl�vti4E�1T' 5 6U(Zv/y AIJv T*NE OFFSETS � 4vuLZ) u uT- U' CaD ro G5'ABIJ% RzO'PEt2.7`I u We, e MAu , f APPLICANT'; �L � E SMALL l 11a &CATQV&PEBARNSTABLE -uC44�.q� LOCATION SEWAGE # / f0`1 IL LAGS Cp,1�znzl //0 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. �L'01 SEP71C TANK,CAPACITY /000 BLEACHING FACILITY: (type) la&& ZY0 (size) 4� "X/0 ` 10.OF BEDROOMS BUII.DER OR OWNER 1"Oo I Ck es w ell ..7 `•PERMIT DATE:_'I' 361 - 9-s— COMPLIANCE DATE: " Separation Distance Between.the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any well's 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 1 hing cili ) Feet Furnished by A ys`` l 2 ya, sTo„eec�' yf, o y y 3G t 31'-10" TO BULKHEAD ---------------- s. 6 7-8 2-1 CV Co M REMOVE IMPROPERLY INSTALLED WALLS j, 1' 2" 4'-2" , EXISTING WALLS TO REMAIN UNLESS MARKED 3'-11" o CV COl " °° 61 LEGEND N 3'-2" 12' O 8' 10" EXISTING WALL o 2'_6" ® EXISTING PARTIAL WALL N ® EXISTING WALL TO REMOVE Wt1 `r REPLACE EXISTING WALL TO REMOVE - '< Cn EXISTING FOUNDATION WALL ELECTRICAL PANEL 3'-6" A � 3'-6" 4._6„ CV i C? M d' C� `v 8'-3" 12'-5" 4'-2" 3' 81 " CV NEW STAIR COVERING T.B.D., BASEMENT GAS FIRE PLACE TO REMAIN Cape CAD Des l9 n HOME RE5TO RATI O N FOR: GENERAL TOTES NOTE: SCALE: DWG. N°.: 1. 50ME OF THE MEA5UREMENT5 ARE APPROXIMATE THE PLAN5 SHOWN ARE THE 50LE PROPERTY OF �1 CONTRACTOR IS TO VERIFY EXISTING CONDITIONS THE DESIGNER AND CANNOT BE COPIED, I/�" R (/�� AND DIMENSIONS IN THE FIELD PRIOR TO START OF REPRODUCED AND/OR ALTERED,U5ED FOR PERMIT P.O. VOX 80�J E LLE N CA STY WORK AND/OR FILING WITHOUT THE IXTRICK WRITTEN 2, ALL WORK SHALL CONFORM TO THE CONSENT OF THE DESIGNER,PATRICK RI MINGTON, MA55ACHUSETT5 STATE BUILDING CODE(LATEST UNDER THE ARCHITECTURAL COPYRIGHT PROTECTION DATE: EDITION)AND ALL OTHER APPLICABLE CODE5. ACT OF 1990. M A f�5T0 N S M I L L5 I I O B U C KS KI N PATH I ANY DISCREPANCIES,ERRORS AND/OROTTENT N 0812 GI20 1 G IN THE NOTES,SHALL BE BROUGHT EN THE ATTENTION OF THE DESIGNER PRIORPROCEEDING COMMENCEMENT CON ENT OF Approved for filing - CONSTRUCTION. PROCEEDING WITH CONSTRUCTION CON5TITUTE5 ACCEPTANCE OF THESE DOCUMENTSAND ERROR5 REV: 508-280-7074 CENTERVI LLE, MA OMISSONDSBEPCCOME THE RE5PONSABILDITYOfTHE 00/00/0000 BUILDING CONTRACTOR 0 Patrick Rimington PLAN NEW TOILET 91-11. WINDOW TO REMAIN NEW SLIDER WINDOW TO REMAIN E[ TUB/SHOWER TO REMAIN 4'-1" 2'-3.. 4'-10" 6' 7'_7„ 2'-6" ----., W2433L W3315 W2133R -3 F\ r O ----- ---- -------- s ml) 824 0 Q 3 O I DISHW24 a SB30 T \ NEW VANITY WITH SINK TOP BATHROOM 24'-1" CV m Ip ® F ® 00 o KITCHEN i bo m T 4 I� -4DB18 B30 BW618� WINDOW TO REMAIN o CLOSET 3-11 r I I I N D CV ann06ozd3 DOOR TO REMAIN W oo sD 00 N 5'-91, 1' 3'-6" 2'-6" — — — — — —� TILE OR WOOD FLOORING 11'-2" 2'-10" 19 T.B.D. N N • ALL NEW DOORS — 14'-2" 2-4 • ALL FINISH FLOORING T.B.D. • ALL NEW R-15 BATT - INSULATION CLOSET' bo CARPET T.B.D. • ALL NEW GYPSUMWALLBOARDBED ROOM r r LIVING ROOM ao bo PROPOSED ; _ LOSETO 1ST2-7 2-3 2'-3" 3'-9" 2'-3" 1' 3' 3' N FLOOR WINDOW TO REMAIN WINDOW TO REMAIN DOOR TO REMAIN WINDOW TO REMAIN Cape CAD Design HOME RESTORATION FOR: CONTRACTOR 1 NOTE: SCALE: DWG. NO.: 1. 50ME OF THE MEA5UREMENT5 ARE APPROXIMATE THE PLAN5 SHOWN ARE THE 50LE PROPERTY OF CONTRACTCTOR IS TO VERIFY IXtSTING CONDITIONS THE DESIGNER AND CANNOT BE COPIED, 1/4 /it`?ii = I I R AND DIMENSIONS IN THE FIELD PRIOR TO START OF REPRODUCED AND/OR ALTERED,U5ED FOR PERMIT P.O. VOX 80 6 E L L E N CA RTY WORK AND/OR FI UNG WITHOUT THE D(PRE55 WRITTEN 2. ALL WORK SHALL CONFORM TO THE CONSENT OF THE DESIGNER,PATRICK RIMINGTON, MA55ACHU5ET75 STATE BUILDING CODE(LATEST UNDER THE ARCHITECTURAL COFMGHT PROTECTION DATE: R I I(/�K�'^)K P EDITION)AND ALL OTHER APPUCABLE CODE5. ACT OF 1090. M A RSTO N S MILLS I I O V V�J 1 1 \I N PATH H I ANY DISCREPANCIES,ERRORS AND/TH OMISSIONS 0(5/2 G/201 6 IN THE NOTES,SHALL BE BROUGHT EN THE ATTENTION OF THE DESIGNER PRIOR TO COMMENCEMENT OF Approved for filing CONSTRUCTION. PROCEEDING WITH CONSTRUCTION _ 7 CON5TITUTE5 ACCEPTANCE OF THE5E DOCUMENTS REV:5 0 7 0 7 4 C E N T E RV I L L S M A AND ANY DISCREPANCIES,ERRORS AND/OR OO/OO/OOoo BUILDING CONTRACTOR N5 BECOME E RESPONSIBILITY OF THE A02 Patrick Rimington PLAN TUB/SHOWER TO REMAIN 11'-9" � 8 � 13 NEW TOILET 7'-2" 2'-4" 2'"2 _ ., 3'-7" 1'-10" 3'-8" 3' NEW VANITY WITH SINK TOP i ]05ATMPOOmj REMOVE EXISTING TILE FLOORING EO — � — — - - 2 8 NEW DOOR LOSETN 2,_2., ' BEDROOM CC i SID N i ATTIC_i - - - - - — 00 bo - - 7'-10" [HATCH i i BEDROO 2,-5„ in i i in N STORAGE ROOM NEW DOOR I - ���O N im ABOVE GARAGE J) co • GYPSUM - a r` WALLBOARD AND I � v 15'-7" INSULATION TO BE INSTALLED WHERE REMOVED • ALL NEW FINISH OPEN TO I ST FLOOR �,., i FLOORING T.B.D. CIDROOM TO REMAIN UNFINISHED CRAWL SPACE AS IS 2ND FLOOR2- - - - - - - - - - - - - - - - 33'-5" ACCESS HATCH TO UNFINISHED SPACE Cape CAD Design HOME RESTORATION FOR. CONTRACTOR 15 NOTE: SCALE: DWG. NO.: 1. 50ME OF THE MEASUREMENTS ARE APPROXIMATE THE PLANS SHOWN ARE THE SOLE PROPERTY OF CONTRACTCTOR IS 70 VERIFY IXISTING CONDITIONS THE DESIGNER AND CANNOT BE COPIED, 1/A II _ I I AND DIMENSIONS IN THE FIELD PRIOR TO START OF REPRODUCED AND/OR ALTERED,USED FOR PERMIT `7 P.O. BOX 80 6 E L LE N CA f�TY WORK. AND/OR FILING WITHOUT THE PAEXPRESSICK WRITTEN 2. ALL WORK SHALL CONFORM TO THE CONSENT OF THE DESIGNER,OP RICK RIMINGECTI M EDITION) AND ALL STATE BUILDING CODE(LATEST UNDER THE ARCHITECTURAL COPYRIGHT PROTECTION DATE: H EDITION)AND ALL OTHER APPLICABLE CODES. ACT OF 1990. M A RSTO N S MILLS I I O BUCKS KIN PATH 1 I ANY DISCREPANCIES,ERRORS AND/OR TH OMISSIONS 08/2 6/201 G IN THE NOTES,SHALL BE BROUGHT EN THE ATTENTION OF THE DESIGNER PRIOR TO COMMENCEMENT OF Approved for filing CONSTRUCTION. PROCEEDING WITH CONSTRUCTION 5 08 2 8 0 7 0 7 4 C E N T S RV I L L S M A CONSTITUTES ACCEPTANCE OF THESE DOCUMENTS REV: AND ANY DISCREPANCIES,ERRORS AND/OR OO/00/0000 ' BUIILDINO CONTRACTOR BECOME E RESPONSIBILITY OF THE A03 Patrick Rimington PLAN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION n y � d h C OV V �e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 no- Oil, Owner's Name: CHARLIE PIERS Owner's Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 f Date of Inspection: 12/5/00 11FC Name of Inspector: (please print) JOHN GRACI Q Company Name: SEPTIC INSPECTIONS �1000 Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes ` _ Conditionally Passes _ Needs Furthe valuation by the Local Approving Authority Fails Inspector's Signature: Date: 12/5/00 The system inspector shall submit a opy 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. Notes and Comments ! F, THE SYSTEM PASSES TITLE V,INPECTION.RECOMMEND PUMPING SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND RAISING COVER TO PIT. ****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 Tncnectinn Fnrm AM S000n " 1 t , t+, j Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) t�Al Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS i.. . Date of Inspection: 12/5/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. RECOMMEND RAISING COVER TO PIT. B. System Conditionally Passes: _ One or more system component''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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a 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. ND explain: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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 bf Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a t1�. L1't tip: Page 3 of 11 ar OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 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 ofa surface water _ Cesspool or privy is within 50 feeti 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 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 tankInd 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and 1�'(, 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. g 3. Other: n/a .Vie,• :�j' Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 ' f D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/s day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n&. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or`privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool oriprivy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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. .,� i 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. You must indicate either"yes"or`ono"to each of the following: (The following criteria apply to large,systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply 'sSI 011 X the system is within 200.feet of a tributary to a surface drinking water supply 4t� X 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,)as failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section 15"Aall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. ;, d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 Check if the following have been done.,You must indicate "yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ 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 X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any ' the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] • S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 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):330 Number of current residents: 5 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How Was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date"installed(if known)and source of information: 1996 Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:—cast iron.X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER , , SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete—metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 81611 H 5711 W Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 2" ~' 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL,COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM NOW AND MAINTAIN EVERY TWO YEARS. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a f - - Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.)``,,` n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .,r Property Address: 110 BUCKSKIN..PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity:n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): THE DISTRIBUTION BOX IS STRi1CTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):NU`'' Alarms in working order(yes or no):NO. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 4p 1i. R Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a n/a Jeaching fields, number: n/a n/a overflow cesspool, number: n/a n/a ;;innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes,or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a `'�" Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a r 11tG t Q Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 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. aC� Dz& no � ry A3� � ' r4f5 3 AD �(6 f ' 'A� , a �11 �P6 in f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 110 BUCKSKIN PATH CENTERVILLE,MA 02632 Owner: CHARLIE PIERS Date of Inspection: 12/5/00 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established tke high ground water elevation: USGS MAPS AND CHARTS- 12+FEET 11