Loading...
HomeMy WebLinkAbout0278 BUCKSKIN PATH - Health I 278 BUCKSKIN PATH Centerville A= 191 - 122 i i i S M EAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10% CeWfiad Fiber Sourcing POST-CONSUMER® www.sfiprogram.org SF141290 MADE IN USA GET ORGANIZED AT SMEAD.COM o ? t a � No. r��� I Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYication for Bigogal �§pgtem Construction Permit Application for a Permit to Construct(Repair Grade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No.�73 ,6VCkXk;" Owner's Name,Address,and Tel.No. C,wre*W//r R orh O'Con*ell Assessor's Map/Parcel l ql, 12 2 Oa6L-sk/�'1 e s-oB-SG-Y-19q,� Installer's Name,Address,and Tel.No.S D signer's N me,, ddress and Tel.Np. Jose," �� C3PI-11, 0021 l E 1 loros ( ,ZE/20✓ mv/^sraws 411.1 s a 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) j?,4/sE �XLMS t/g '�.9_,p7-1e r.4el< G �� 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 Certificate of Compliance has been issued by this Board of Health. Signed Date 7 �7 1 Approved by Date 1Z7 �'� ,Disapproved by; Date {wing reasons `f. it No. Zoon r04F.,� Datelssued No. �� -. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ r' PUBLIC HEALTH DIVISION -,.TOWN OF°BARNSTABLE, MASSACHUSETTS Yes Apphidtion for Bi5po5a[ *p5tem Cow5truction Permit Application for a Permit to Construct(zj'-Repair(grade( ) Abandon( ) ❑ Complete System 91ndividual Components Location Address or Lot No.2 73 &16k -,k i4 1),Wr"h Owner's Name,Address,and Tel.No. Cr,Nrl=rlii//1�zr R vrh O'Cone-ell Assessor's Map/Parcel /q1 122 `,78 13a4k-Sk1;1 /4-rh Installer's Name Address,and Tel.No.��S _28d-77�� D signer'sI�ame, ddress and Tel.No. S-OS-S"G3-�9qy 4 JesePti �G 13�t^voS �oyn jJo y2 F -SO /�►r S 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 f Design Flow(min.required)- 1 gpd Design flow provided gpd Plan Date f Number of sheets Revision Date ` Title f r' Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable){ ��/.5 L'wrina �N.. . - Zh S lw// Lr_r�►�li ih�.�i.%� /G X 3� 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 Certificate of Compliance has been issued by this Board of Health. l f Signed yti� J�� -may Date L ApplicationApprovedby J�4/u. e . Date 1/ 74-7 Application Disapproved by: Date for the following reasons r ^� Permit No. 2Go 7 U�� Date Issued 1?�� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site SewageDisposal System Constructed (�-) Repaired (� Upgraded ( ) Abandoned( )by d n�✓/obi 12p66��' at �?72 &,-k-Sk'i 11_9,697l has been constructed in accordance /� with the provisions of Title 5 and the for Disposal System Construction Permit No. -2 D6 ' 'o k-2 dated 3 1/U" InstallerJoSe/q 0,, Lqf¢^YOS g LI`I �Du�/= h�SSOG/ ?��S 1 Desi ner 6 #bedrooms ,3 Approved design flow 3 C) gpd { The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. CacJ _. Fee X/_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1wi,5po!6at �&pgtem Cow5truction Permit Permission is hereby granted to Construct (e_—) Repair ( Upgrade ( ) Abandon ( ) System located at 53UGL s kl4y "w7A h tFY 1/i 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 permit. Date 3 +7I� 7 Approved by v TOWN OF BARNSTABLE LOCATION �'7$ - l�v��'S��idl f�TLi SEWAGE # V` L�,AGE ASSESSOR'S MAP & LOT/9/—/?2 INSTALLER'S NAME&PHONE NO._�D�` �f10-5�'�38 rfoS�i'�� �G .sJ ►t�yS SEPTIC TANK CAPACITY 140 LEACHING FACILITY: (type) z4o,44FF�� (size) NO. OF BEDROOMS 3 BUILDER OR OWNER an PERMITDATE: COMPLIANCE DATE: 3-1Y-07 Separation Distance Between the:. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet t. 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 leachin faci 'ty) Feet Furnished by i i • 3o I` zP/SP�i� PiP� Town of;Barnstable . _ Servi Iaegul�atory ces Thomas°F Geller,Director P"Uc Re'A th Division Thomas.McKean,Director 200 Main Street,Iiyann's,MA`02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 14 1,0 Sewage Permit# 06 -o&z Assessor's MapTarcel Designer: J a h Installer: Address: I2U e M,&:f,Az 45'lA° Address: �r. -410f,9 r On 3- 7-o7 L.se of Ve 15,��v S was issued a permit to install a (date) (installer) septic system at ol--7 6 BVGY:�5K!nl PATH based on a design drawn by (address) J. Dy te- y-5S6C. dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. st is Signature) �' D�, . 1140 `. U TAR1� esigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU. Q:Health/Septic/Desiper Certification Form 3-26-04.doc i Town of Barnstable 0p 114E 1p� tia Regulatory Services Thomas F. Geiler,Director + BARNSCABLE, 9� ' ASM .•� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office:..508-862-4644 Fax: 508-790-6304. January 10 2007 Ms Ruth O'Connell 278 Buckskin Path Centerville,MA 02632 ORDER TO.COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located at 278.Buckskin Path, Centerville, MA was last inspected October loth.2006 by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts..under The inspection of your septic system showed that your system"Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leaching field shows evidence of backup into D-Box with stain lines 2" over outlet pipes. Tank has no outlet baffle You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALT DEPARTMENT om s A. McKean, R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION t SOW SVey TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 278 Buckskin Path Centerville MA 02632 Owner's Name: Ruth O'Connell Owner's Address: Same Date of Inspection: October 10,2006 Job#06-274 Name of Inspector: PATRICK M.O'CONNELL ` Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD — MARSTONS MILLS MA 02648 ; Telephone Number: 508-428-1779 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 bas d on myj- training and experience in the proper function and maintenance of on site sewage disposal systems.I at a D $: yt�t�t approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 1111����� OF _ Passes ,� r Conditionally Passes ' ��• P '�rtlC :N •m Needs Further Evaluation by the Local Approving Authority X Fails 01 f Inspector's Signature: fin _ Date: 10/10/06 '>�!F5 I;uSPCG� •�` 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. Notes and Comments: leaching field shows evidence of backup into d-box with stain lines 2"over outlet pipes. Tank has no outlet baffle. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 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: 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. Answer yes,no or not determined (Y,N,ND) in the 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. ND explain: 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: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 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 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 I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: 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_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 _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 or privy is within a Zone I 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_(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. 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"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 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 of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR I5.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): unknown Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a Number of current residents: 0 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): two years total: 179,000 gal.=245 gpd. Sump pump(yes or no): No Last date of occupancy: unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components,date installed(if known)and source of information: Late 1970's+/- 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: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: V Material of construction:_X_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:8.5'long x 5.2' wide— 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Outlet baffle is missing,liquid level at bottom of outlet invert GREASE TRAP: No (locate on site plan) Depth below grade:__ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 i TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): Liquid level is currently below outlet pipes box is deteriorated and leakine Observed stain lines to top of box. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _leaching chambers,number: _leaching galleries,number: _leaching trenches,number, length: _X_leaching fields,number,dimensions: One field 20 x 20 _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.): Lateral lines are full of solids and partially collapsed due to excessive roots Field is in hydraulic failure showine evidence of backup into d-box CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 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. Buckskin n Path � Water Service 15 17 7 ban ,, ffl to a Now . �- Page I 1 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Buckskin Path,Centerville Owner: Ruth O'Connell Date of Inspection: October 10,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water 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) _Accessed USGS database-explain: You must describe how ground you established the high Y g g d water elevation: A perc test will be performed prior to repair to determine groundwater elevation. I TOWN OF=TABLE L1'ION � QC SEWAGE # VILLAGE ASSESSOR'S MAP & LOT SEPTIC TANK CAPACITY �f LEACHING FACILITY: (type) �b (size) NO.OF BEDROOMS . BUILDER OR OWNER w - PERMITDATE: ^\%\ COMPLIANCE DATE:' Separation Distance Between t Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist V o site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist w in 300 feet of leaching facility) Feet Furnished by Buckskin Path a.^ Water « Service I 1 f` 15 17 7 1 �� I Town of Barnstable P# i Department of Regulatory Services ? tr,►.Mp� Public Health Division Date J j 200 Main stre t,H"inm Date Scheduled �� Fee Pd, ®o Soil Suitability Assessment for Sewage Dis o alp O 4�a , D P Performed By: �TUbi'l/ �. .D 0 Ye.C T l..S � Witnessed By: LOCATION& GENERAL INFORMATION Location Address Owner's Name /�11ry e 'LDi1Jit/EL Ci!5�1 2�5 1.71-1- I Address Z/S D�9 13 S 7- . Assessor's Map/Parcel: 1)7, a4,,CC • 12 2- Engineer's Name NEW CONSTRUCTION REPAIR Telephone# 99 Land Use /�t-S'�L��j�C 2 Slopes(%) Surface Stones /t/a7` ,5ffS"try Distances from: Open Water Body Z o o ft Possible Wet.Area Z O O ft Drinking Water Well 9�G_Oft Drainage Way Y ft Property Line _ �•�ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands#n proximity to holes) Z Z / s 87.6 , Parent material O to is S��D Ali . g ) Depth to Bedrock ��7^�KS Depth to Groundwater Standing Water in Hole: f+ Weeping tram Pit Race Estimated Seasonal High Groundwater .314• `-7 D TERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: 2//71 j Depth Observed standing in obs.hole: /2 9�. in. Depth to soil mottles: In, Depth to weeping from side of obs.hole: In. Groundwater AdJustIne11 Index Well#l id Reading Date: Q G Index Well level 2. 2— -- 7. Adj.fhctor Adj.Groundwater Level 3 , Sc7 PERCOLATION TEST Date Observation Hot# TP-/ Time at 9" Depth of Perc -36 ��.J Time at 6" Start Pre-soak Time C /O,'Z Z ;D O 15me(9"-6") End Pre-soak 3 3 =/U Z Y 6.9Z sr�dl4jTE RateMin✓luch 4 2 /YI Site Suitability Assessment: Site Passed�_ Site�Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----' percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) , (Munsell) Mottling (Structure,Stones;Boulders. Consistency, v 20 54,(10 ZS Wy sh Z pl 2 1" -11J 54AID 7,`s yA b-1 'l- 33 18 59/✓D 104M /oy . s/ 12 1"-13:L C z F//16 SA A(, G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Qrave DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consistency. s Flood Insurance Rate Map: Above 500 year flood boundary No_ 'Yes Within 500 year boundary No V' Yes Within 100 year flood boundary No 1/ Yes .� Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? %G S If not,what is the depth of naturally occurring pervious material?�..� Certification I certify n —_� g (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by the consistent with . the required trainin ,expertise and experience described in�10 CMR 15.017. Signature Date -L---- Q:\SEPTI0PERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form i c1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path T Property Address l,;y Carolyn Carr ' Owner Owner's Name information is Centerville MA 02632 1-10-19 required for every page. City/Town State Zip Code Date of Inspection P%a i;J1 1:0 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. A. Inspector Information 514 13Si3 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1-10-19 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 has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ` ITitle 5 Official Inspection Form 111 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1 2 3 or 5 and all of 4 and 6. P rY P , 1) 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: System is in good working order with no sign of failure. 2 System Conditional) Passes: Y Y ❑ 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 ' Commonwealth of Massachusetts 3, Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ON ❑ 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts i-1 Title 5 Official Inspection Form Yal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. -Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c ` Commonwealth of Massachusetts Title 5 Official Inspection Form ! w • 16I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 r than '/Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. EJ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply I ❑ ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >" 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? ® ❑ Wasthe 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 L''' Commonwealth of Massachusetts r� Title 5 Official Inspection Form r I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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: 1-2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ,r 278.Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is Centerville MA 02632 1-10-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner--pumped 2 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form '• i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path `J Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i)l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 6" 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 Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 r Commonwealth of Massachusetts / Title 5 Official Inspection Form I.,. I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts r1: Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 8. Tight or Holding Tank (cont.) 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 9. 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.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts r� Title 5 official Inspection Form %I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-16x30 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order with no sign of back-up into d-box or surrounding stone. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ! i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 03 a r __..:....._■ _._..:............ 'i.w�w.ww�is+sn�i'�rni®iw_. i�A6wi��e w®s ®"..� t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments >k` 278 Buckskin Path Property Address Carolyn Carr Owner Owner's Name information is required for every Centerville MA 02632 1-10-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 18 of 18 E# /' G SEWAG VIIAfE ASSESSOR '.p°t3wQT I1�STAi.LE�`g.I�tAli►1�&3'lIt31►tE N{1 Sffi�fiLC TA-K CAFAt�TX "LEAC�IIL�IG pro c �a�n oohs. = BUILOPMOR cow Sepera�nn i?tstsnce Between Ehe `: . Maaaatum Ad)usted Groundwater Tate to the Bottom of Leaching Facility Feet exist Pnvat mat erSupOOV- e11 asidLeac�sng Facility f orbaay Feet" an site ar unthun 200 feet,of leaching fail Edge ofTetiand and;Leachtpg Fact ty(If any wetlands eusf Feet vntbla 3tIX}feet €:.eaclutg faces? S Rom" , o a i gt3 -3 8c. .,-LOCATION SEWAGE PERMIT NO. VILLA E ! ( q FNSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i 0, � �)ISJ;" Z0,4,v7" 1'�20AV 5-6WA 6 e SYS T�tiI P!c'DF'/L� 70 A117-IIAI .5'40/1-S 725s 7 h'ESUG 77S /n/lsy G,2,4 d Mlw, o� p SG D F'� �� � !o S,q N,Dy co f/ER gilt!/,v -�'" ��sErZ y„m i". CO V459 WI7-IIIV 6" 7 SYX s/z 4404AF A Oic F1Al, 69, /1N40 zj �o vER RISER � AND 2 cov6R bF l - 2sWOA1 daS� T 7,sYR COVER '3;9A/4 GLgU/D G�16G. PVC wN1aS 29�„�PVc E d AV / IN t M� /y� v IAI v iw v . 4-3,3 7 /o Y,P 154 G o.9N/ ,g /r'ti/G! �3.S Z c3,2.4 2 4 YC F' P� TEE �3,G 9 , � •` T-._ f' / v / 3 -L, 5�2, 37 .rr �'N�=.t> �'7"c�N� �'G. 4�-.z.8,7 CXU 30 5. Q ME,D/UiYJ :570NE W/ 6 b 8 2 /dY/? r4 r�3 7"1.f.S`T� 1,� I�/��/ �,C'c�tJlVD Gc.�..�17"�=�' ��.. 3 �.,�?,' - � p _ /307`TOAI , UI= S7" P,17" fZ- , .33• 9S ,� 6,eooyp A1,47eff IZ 9 /2 X1 /h/t C /VC-X-.3/A/G ��F'.R/P5' . T�9iStK �5'h'AGG. iayR B/� s.�w,o •41s' 17 O.'"..�3 �".6C-7-j t�C TE ,� GG.k/ �/ZOl//tiCDd+t/ e� . J .r9 = U*' .3 ' 72 1 , 37 97 0041e Z5,OW- 2SZ 6:A D1/JCS cz � i4Z`�sf G. �" ,�7 .��.;�e.t.s`�'"".,?J �r'hi�D . S' D' h' A Re-RG.ACE� k1 T� /S44 6,�4G r 2WA-Ik /3 " �'G.33, q5 !�' ? ! 515PVA6C 5 SYs725M D AF,51CA1 9"M/nt. �E.f'���EA Gf1? /2lIL S u 10)= iVSTA,BGE O.,Al. D/V/V d " AI C�vE�2 ,8 .� A M/ .2A z�/ /g l s aaNAlqLA 33C, ? G� 5 0/�sY�9L U9To�e: <10 t/N �o yG E r •a p�.�2C. ACA7� =< z .M•//V. P� //VC /�' /`l l >tit • f�'' c G�, ' dY .at° .G s" P��eC. T2•s .�Th� -- ' /12 ' .DOt� LE v1/ASN „D STtJNE fi ?" T i 71''T1�f24L 2 Gs ,6,0 ' �955��ssDR,:5 MA, !9/ 'a�9x'C .nhL� S�C T/ON ,,,fvor�s . I, G L G'�it/°5/. U T/or~! fv" �/lh T �f• ' S t5' A t. C'4�Slr=c :'/11 r q TO � 7` LL. EC E.D / 'o �t/5 T .4N�' �S'6,�.9 BE fiv�P ?^ �,'"'TG:� /!! f�i't/,I3 ,d'o9.�ivKS'T.9�.G.� $.D, S7.O'UCT-61RA4 /i✓�G,e/Ty .�4AZd 2. 1/1//StS��,f� �57'o�v� 5 6/1'f,` Z- .f" - 1 :6, 0,,K 011.5`'T AAI. � J (/�SlC7f4N!/1!�- ��f GqC� 1�/T6/ ��o© ,3tLLUi !7" ,d�.S�,G L Wi9?" =�'C' ?lh✓ L. ! ��C�S yX/S Nti9 G L .a ?�1iY•� Y T! �i9 e .firms L7 s,�/si' G 8 3.S'`•� 9. 'CEG 'O. /22 Q o° o tV , ZW-5 T/N f /aoo 6.4L-. 36 ^ 5 GvAy ROV7� Z S ; v G'r`" �' ,Yi9G RoP._ s ft'diA7GC/�?L IIV T�/� -5 41. �,A A AV4 4 .5 � r (�' ib j -_ A •`7 G ff 7� 'A G .{'7"�/s/.`�l4i/ 7- ' 4 Z�Ga1�t//ti! 7"4 n / aaX _ o u I 501� i 'G,9 C,6 W/ C :,6 .N t1 S �ilA.� scq�E. , i , l l Assd rro�/ ✓.v ,�ccr��e n wIT� I:3lo c/L,az /<".2 s-C3 / z000 AoQj 13 J Y + S. , _ loA !M EG.. 5�8.54Z \ r- _� LE M q� 9 ^ j . r-y � , No.. ,1C+a OGEE/' 141 33 `'`'"`�-,a.,, IV t?A l—, �0 9_ ma's-• � - � �$��° S.9RN�T.�I,BG,� � M9 . o 1 ; ,QL-Vl..Te� o�V= Z- z'8 , 07 4 /?lU CG aY�RF/�G 1� Lt/Y E.SAL.M4 U?y 4ZJr.3 G _-