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Home My WebLink About0306 BUCKSKIN PATH - Health 306 Buckskin Path Centerville A = 191 125 UPC 10259 No. H163OR NAAl*�N O$ YN i A ay 04 2016 20:29 Jim The Inspector Man 5085349919 page 1 ■ '�• <L\� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -G 306 Buckskin Path Property Address �..� Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every page. City/rown State Zip Code Date of Inspection 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 D filling out forms SI - I Jt p ``��pWuuuup�r�i on the computer, OF use only the tab 1. Inspector. ;�� •'' �'' c'�', key to move your cursor-do not James D.Sears •LAMES use the return Name of Inspector ==� btARS r key. Capewide Enterpises LLCCompany Name 153 Commercial Street oiF s I N SPE�;o\`\� Company Address were Mashpee MA 02649 City/rown State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority '25-3-16 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future'under the same or different conditions of use. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 May 04 2016 2029 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and five chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or.repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3M3 y Title 5 Official Inspection Farm:Subsurface Sewage Disposa System•Page 2 of 17 May 04 2016 20:29 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page. Cityfrown 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 (cant.): ❑ 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, f 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•3fl3 Title 5 Official rnspection Form:Subsurface Sewage Disposal System•Page 3 of 17 May 04 2016 20:29 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owners Name information is required for every Centerville MA 02632 5-3-16 page. City/Town 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 El ® Liquid depth ink is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurfeoe Sewage Disposal System•Page 4 of 17 May 04 2016 20:29 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every page, Cityfrown State Zip Code Date of inspection B. Certification (cont.) Yes No El ® 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 16.303, 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. 1 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-3113 Title 5 Official Inspection Farm:Subsurface Sewage Dispose System•Page 5 of 17 May 04 2016 20:29 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name Information is required for every Centerville MA 02632 5-3-16 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): 4 Number of bedrooms (actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 May 04 2016 20:30 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and five chambers. - 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014-7 ,000Ga's 9 ( y g (gP �� 2015-79,000GaI's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commerciallindustrial 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 Dispose;System•Page 7 of 17 May 04 2016 20:30 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form NNW Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page. Cityrrown Stale Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2011-2014 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/Altemative 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 Dispose.System•Page 8 of 17 { May 04 2016 20:30 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every page. CitylTown Stale Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of Information; 2001 Permit#2001 -755. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain); Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 21" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age; years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10. 18" Sludge depth: t5ins 3113 Title 5 Ofkia Inspection Form:Subsurface Sewage Disposal System•page 9 of 17 May 04 2016 20:30 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 12 2" Scum thickness g, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and outlet cover at 21" below grade w/inlet cover at 6". In and outlet tee's. No sign of leakage or over loading r 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•3113 Title 5 Off clal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 May 04 2016 20:30 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is Centerville MA 02632 5-3-16 required for every 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: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 May Q4 2016 20:31 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 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.): D Box is 16"x 16"-44" below grade w/cover at 2'. Box is solid w/two lines out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass.. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: •Sins-3A 3 Title 5 Officia Inspection Form,Subsurface Sewage Disposal System-Page 12 of 17 May 0.4 2016 20:31 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 306 Buckskin Path Property address Charles Lawrence Owner Owners Name information is Centerville MA 02632 5-3-16 required for every page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is five infiltrators w/2' stone. Ck D Box and camera out to chambers. No sign of over loading 1"water in chambers t 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 t5lns-3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 May 04 2016 20:31 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:StbsurfaceSawage Disposal System•Page 14 of 17 May 0,4 2016 20:31 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form VFW Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i1 l _ r? D, .13 - 33 , .5S � a o �-3 - s _ J3 s�- �.—— _— '3 T � t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 15 of 17 May 0.4 2016 20:31 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts mi�k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owners Name information is MA 02632 5-3-16 required for every Centerville page. Cityrrown 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: 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: 12-12-01 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: T.H.on Design Plan 12-12-01 no G.W. at 12'. Bottom of chambers at 6' below grade. Bottom of chamber at 6' above T H Depth Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:suDsufaoe Sewage Disposal system•Page 16 of 17 May, 04 2016 20:31 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Buckskin Path Property Address Charles Lawrence Owner Owner's Name information is required for every Centerville MA 02632 5-3-16 page City/Town 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 A t5ins•3113 Title 5 Official Insoeclion Form:Subsurface Sewage Disposal System•Page 17 of 17 ,qLa No. '/�/ f Fee�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Nsposal 6pstrm Construction permit Application for a Permit to Construct( ) Repair(Y Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 30 I3Uc<N/,(N -PA Owner's Name Address, d Tel.No. Assessor's Map/Parcel �'( + �� 39, 4 0 L owl*(_ W A-Y \AIGS Installer's Name,Address,and Tel.No.502—(417—819 7_1 Designer's Name,Address,and Tel.No. 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) Pa uteArz- Lc e i=--Aom H o vsi5 -m s&-P T t C �,409, 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. S' a Date df�D/ Application Approved by Date 3-1-7 IJ CP Application Disapproved by Date for the following reasons Permit No. ��ty 3 Date Issued 7 No. -- --TH€'"COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �Wication for Mis'pD8al 6pstrm Construction permit Application for a Permit to Construct( ) Repair( bpgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 30 13UCgN411j 'PA-.T:�4 Owner's Name Address,and Tel.No. L' '�!II.Lt✓ . Cr1�Rc�5' (.�q tn14GN�"' Assessor's Map/Parcel q ( oZ 3� t'oc.ot�e W>k`f W&ST Installer's Name,Address,and Tel.No.Sp$•(477-88 71 Designer's Name,Address,and Tel.No. 1 IvISC�4Pt:Z� 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. x Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4,1 M H o 1JS S7&-Pv<�. --TAX Date last inspeg�ted: t Agreement: The undersigned agr!esto ensure the construction and maintenance of the afore described on-site Y sewage disposal system in P 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. ,1 Si Date -yr a� `a d ) -, Application Approved by Date (! +� Application Disapproved by ``' Date for the following reasons Permit No. ��/ Z,3 ip Date Issued L- - / ----------- -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS �_w 1 BARNSTABLE,MASSACHUSETTS I ^Q Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �) Upgraded( ) Abandoned( )by CAVC—k>1D G LAC. ...,r at 17 —PA-r - 'y!L has been constructed in accordariee ,�_(IucxsKtx� c.f .9 with the provisions of Title 5 and the for Disposal System Construction Permit Nd)91&—13 & dated Lf l �0 h Installer G4DELJ1D6 GoyE!x Q M (��-�. Designer W 44 t #bedrooms (\, 1 �' Approved design flow // �' gpd The issuance of t 's p rmit shall not be construed as a guarantee that the system will nct Pas design! Date I Inspector V V- !`�r ----------------------------' --------------------------------------------------------------------------------------------------- ---------- --- ----------------------- -------------- No. (O /� �J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal bpstem Construction permit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( ) System located at 3 0(,, UGK S K aj PAT/- 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 O/e�compl ted within three years of the date of this pe it. Date d �`�/J Approved b TOWN OF BARNSTABLE � 1 LOCATION 3cC, �V`1�ks-�,= Vl SEWAGE # I' d }dS VII LAGE (RiA le,( V i ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. i�►�k �i3��t� �ra�-S 6.t 95.9 3C 3- SEPTIC TANK CAPACITY L t� LEACHING FACILITY: (type) NO. OF BEDROOMS Li BUILDER OR OWNER �2e�v� i�U t 1'1►1 PERMITDATE: I 'I —6 Y 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 ` �)S ,50 C 3� ` D = 33 'Dwe-th-ocl 0 Ss ' (3 - S, col = L }, QV f� .;r Fee '-.65-Z el THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYtcatton for Dtopaal *pgtem Conotructton Permit Application for a Permit to Construct( . )Repair( )Upgrade( Abandon( ) 2tomplete System ❑Individual Components Location Address or Lot No. 2.06 c � Owner's Name,Address and Tel.No. Assessor'sMap/Parcel /�/ `�lck-ee- d eN� �`Npr�a e a,$ rvl�,ra l v4� Sa - y 2 7- - 9 ss 5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S-og �3 j al $3 �aq✓�� Q� S ✓x�.� , tom, r/Ulc. Dec C-null-ol ;l-d .ems,9,Y?S Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder 0 j) Other Type of Building �J No.of Persons Showers( ) Cafeteria( ) Other Fixtures (� Design Flow ,/qo gallons per day. Calculated daily flow l� � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ��5 a l tf-/U Type of S.A.S. A' CA.] - yS w s.�Cwe Description of Soil 5 S Nature of Repairs or Alterations(Answer when applicable) 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 E viromn -E and not to place the system in operation until a Certifi- cate of Compliance has been issued f Signed ZI Date Application Approved by Date Z �- .Application Disapproved for the following reasons Permit No. ;o "d/- ��' Date Issued �� aN-o ��✓ Fee 'f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ves :` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS _ � 1 01pprication for Mi!5poga16p.5tem 9;ongtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) Cl(d' omplete System ❑Individual Components r, Location Address or Lot No. 306 Sj�,ksk_f V0 ff�_WC., Owner's Name,Address and Tel.No.S�� (�J i✓1 h c� �iC,�Pr�.� uva ye Y�vP�da e Assessor's Map/Parcel /��Ila-5 ► V l Ll S-d ,,- c./?7- - 7 SS 5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 917 ' 'PA t'-z�. £K c:v�►�Yd-�„n� t�'t`�l� �'1/IuSO w K�.�. g3 �a4✓cl �e� R� 5� ,.� ' � L7 VMCA ID13C Fnc�lYor1.9,C�ti�gl >S,7Y? Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder 04) Other Type of Building S t Je At4iL)� No.of Persons Showers( ) Cafeteria( ) Other>Fixtures U Design Flow yY o gallons per day. Calculated daily flow /�' "� gallons, Plan Date /d- 4 - u / Number of sheets / Revision Date Title p Size of Septic Tank 42�) Pico /N"/C7 Type of S.A.S.,S /1'4 Description of Soil; 5_.O all c.✓I h S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: t 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 E vironm a-G—e and not to place the system in operation until a Certifi- cate of Compliance has been issued s oar f y l Signed Date Z Application Approved b Date Application Disapproved for the following reasons Permit No..-4Vb Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded( ) Abandoned( )by pASh""e— !L x`a uea.Av"i at 30& E I.-,CAC S k(h (!P�q 4-1- has been constructed in accordance with the provisions of Title 5 and the for isposal System Construction Permit q y �'� � dated 10, 17�e' Installer PAX4v�. i Xtr4�4 t,v j Designer D 0409orJ The issuance�°f this permit shall not be construed as a guarantee that the syste will, nction A desig d. Date �� 1/1 01) Inspector— � No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Mizpogat *p.5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at t.7 ur' //e - r 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�iermit. Date: Approved r TOWN OF BARNSTABLE - LOCATION �� ` �` to SEWAGE # �-�� VILLAGE ('R&A ' �✓i�� '� ASSESSOR'S MAP & LOT CI J. z INSTALLER'S NAME&PHONE NO. +�� ' �a,�S t Z �I �' Soo SEPTIC TANK CAPACITY 3ey-�V 0 LEACHING FACILITY: (type) �i C ie) NO. OF BEDROOMS BUILDER OR OWNER S,*c%v1J PERMIT DATE: COMPLIANCE DATE: �l' 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 i 1 71 � � = 33 ) r3 1 y TOWN OF BAMSTABLE LOCATION0' ` '�� -I�'� SEWAGE # �' � VILLAGE k4'y 1 ASSESSOR'S MAP & LOT Z INSTALLER'S NAME&PHONE NO. �t�k �i �l"%f� (ZiaLS 6!t ;EKC\I. 4m�t'i ko, SEPTIC TANK CAPACITY A- rr + LEACHING FACILITY: (type) e) NO. OF BEDROOMS BUILDER OR OWNER .>IrxvJ �(!u 1�1►1r? PERMITDATE: I 'I '4 V COMPLIANCE DATE: U O y- a 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 r�y d � y of Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Pr , Jolut Gf aci One winter Street,Boston,Ma. 021 tit e X�l E.P. Title V Septic Inspector ,moo O �If�+E P.O. Box 2119 F ® w Teaticket MA 0253E WILLIAM F.WELD TO C `� 199 S -6&13 Governor Oje�Ns h ARGEO PAUL CELLUCCI HpfpTAB[F Lt.Governor SUBSURFACE SEWAGE DISPOSAL M INSPECTION 16 PART A s CERTIFICATION L g Property Address: 306 Buckskin Path Centerville Address of Owner: Date of Inspection: 11/5197 (If different) Name of Inspector: John Graci Estate of Robin Hodder I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) l `� Company Name,Address and Telephone Number: strl( 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on crlterla dented In TRIe V Conditional) asses code 310 CMR 16.303.My findings are of how the system is y performing at the time of the Inspection.My Inspection does _ Needs urt Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevttyofthe Fails septic system and any of Its components useful life. Inspector's Signature: Date: 1211197 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: c A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised=7197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 0 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:1115197 _ Sew.aae backup or.breakout or hiah.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary io a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised WNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:11f5197 D]SYSTEM FAILS(continued) 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 than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. if the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (reylsed 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 305 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:1115197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X_ The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:1115197 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if avaiI able:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:0 gallons/day 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: We Last date of occupancy: rda OTHER:(Describe) We Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source Information: 1970 Sewage odors detected when arriving at the site: (yes or no) No pevlsed 04127197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:1115l97 SEPTIC TANK: (locate on site plan) Depth below grade: rda Material of construction:_concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Na Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance form bottom of scum to bottom of outlet tee or baffle: rda How dimensions were determined: rda Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: Na Scum thickness:rva Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumping;,, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Na BUILDING SEWER: (Locate on site plan) Depth below grade: r Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line?o- Diameter: 4"_ qv, mments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:7715197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rya Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rde Capacity: rda gallons Design flow: rya allons/day Alarm level:_nia Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rya PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rya (revised 0427)87) I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 306 Buckskin Path Centerville Owner: Estate of Robin Hodder Date of Inspection:1115197 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: rda leaching chambers, number:We leaching galleries, number: rda leaching trenches,number,length: n1a leaching fields, number, dimensions:rda overflow cesspool, number:7'Dxe'wblock Alternate system:-rda Name of Technology:_nra Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The overflow Is structurally sound and functioning properly.a was empty at the time of the Inspectlon.pti hag not had more than 2'In It CESSPOOLS:x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: empty Depth of solids layer: nla Depth of scum layer: rda Dimensions of cesspool: 7'Dx6'w Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Main cesspool and all components are structurally sound.Recommend pumping system everyyear for malntenance. PRIVY: (locate on site plan) Materials of construction: rda Dimensions: nla Depth of solids: nla Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nfa (revised 04J27)97) , c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 306 Buckskin Path Centerville Estate of Robin Hodder 11W97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locatewhere public water supply comes into house) rJ�^CI� A S�to ee Pap• ! of 10 (revleed GMT197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 305 Buckskin Path Centerville Estate of Robin Hodder 1115197 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Chart (reviaed04 V97) _ page 10 of 10 -- ---- -- ASSESSORS MAP TEST : HOLE LOGS wn PARCEL: SO I L EVALUATOR: a ° _..___. _- WITNESSE:FLOOD ZON /OT REFERENCE. - - DATE: / � PERCOLATION RATE: 2, /YJf / - __.� :_Z�_..��. _�J.( I'l- . 2L-_. N.L✓:--- - �' t I TH---------------- -2 TH- _ .:_ _W - _ __- n t3 LOCATION ON MAP 6/1, ' bo ppG� .w __� _ I '�C •(_ 5 h (., lr E� _..1 ..._h?l 1�t2 C,? �rC�CZ. L ,1 Cfi 1 ' _. � . _ SEPTIC SYSTEM DESIGN _ .... :....._. "(� ....,_-_�5,�q-► , . _'"ice_..._ . O :FLOW ESTIMATE BEDROOMS AT �� GAL/DAY/BEDROOM - �bGAL/DAY SEPTIC TANK 10 _ GAL/DAY x 2 `DAYS - GAL N�FM'Ss9 DO NALD CS [aAVID USE / �GALLON SEPTIC TANK L N B. ' I --- 3 DeLANO l v No.29868 y <. " SOIL AB ORPT I ON SYSTEM P ,� 106A )G,/ L / UW,D►E�; t 0 SIDE AREA: :... X aq,LSf /dig X x, BOTTOM AREA: / b C� .-.,r 1*41 .. , PT I C SYSTEM SECTION lop or ocyrt V �wlk� al, 13ro _ o-Bo 9, , GAL SEPTIC TANK U +"b �1►�" X77-1 SJ TE AND SEWAGE PLAN LOCATION : #u06 PREPARED FOR ?467Z) 0# 0 SCALE: DAV I D B . MASON DATE: DBC ENVIRONMEN AL DESIGNS y EAST SANDWICH . MA DATE HEALTH AGENT 8 ) 833-2_I77 - - __( 50 -- -