The URL can be used to link to this page

Home My WebLink About1153 BUMPS RIVER ROAD - Health 1153 Bumps River Road Centerville A = 188 090 Omrford, NO. 152 1/3 ORA 10% J � f c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town 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 filling out forms A. Inspector Information /3(,a on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 E,y Company Address Sandwich Ma 02563 City/Town State Zip Code rxm (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I 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 the property 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 � q Brett Hickey %•a-.� ��.��s 3-18-19 ��Oate:A19.m21 15:1k.N L6W 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 gpd 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 19" Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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. 1) 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 was in working order at the time of inspection. 2) 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): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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 ❑ 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): 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 ,p Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 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 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructedpi e(s). Number of times pumped. ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O 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. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ a 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 ❑ ❑ 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 1153 Bumps River Road v Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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 ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ O Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ o 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ a 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 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road /V Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms(actual): 330/gpd DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes [E No Does residence have a water treatment unit? ❑ Yes R] No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes EI No information in this report.) Laundry system inspected? ❑ Yes E] No Seasonaluse? ❑ Yes Q No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2018- 160,000gallons 2017- 91,000gallons Sump pump? ❑ Yes M No Current Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � lol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road v Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: 3-3-03 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 41611 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 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; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 316#1 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 1 Dimensions: 500gallons 511 Sludge depth: 3111 Distance from top of sludge to bottom of outlet tee or baffle 2rr Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form - la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road L Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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 0 No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: (2)500 gallon chambers 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Offidal Inspecfion Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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.): SAS was in passing condition. Chambers were 1/2 full when viewed with no higher staining. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration NA 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 c°pe� Commonwealth of Massachusetts �s ac Title 5 Official Inspection Form oaf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 1153 Bumps River Road Property Address Felix Shneur Owner Owners Name information is Centerville Ma 02632 3-18-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road u Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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 Assessing A"s=Buiit.car 's ftt� TCJiiI[+I Of BARNSTAKLE � t L toccw r Qx Gt. i Ra sEWA4ro E-rt.Aevr vzLxi�c R1S are`LOT, Ar T s ts�,pt:j ME-&PHONE No. SBi'ITC''1}►7QK.G`APAtCrrY -/$7 ir.rt T.EACH7IVCa FAC7LTr-Y(ry rro_aF�>srsxcrcius,, 8L)2t33ER i7 0'` t PEtiLL1r_: ATE:' j. CUMI!E IANC& E?J1 YE; 61,"i.. Sepezoktps thstance Hativeai t31c;. Maiimum Adjuserx Liromi[iil vhttr Lblzte fa JseBot nm t�f7 rx caching-.Il xLty 5W a' F; j'rirxte Vvergr;Stitq Well ao+Q i ca6cliitg Pse�loiy (Yt aAy'wr11s cxiar ou=zirc or gnthia 2tl0 feec-oP ;. Feed.. ii fa�7�tyj ,. " - . -FiiBc efE'Wetland aael mpg Pacehifiy.{3t?itY!�W+ds e�r3sz - •�: withia 3Ot)Iaet�'o Jar.t g fpoiti;Y)', Feet Fu CtliShCd by suer h �E S t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every page. Cityfrown 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: No GW @ 120"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: 2-14-03Date ❑ 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) i ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7r M/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Road Property Address Felix Shneur Owner Owner's Name information is Centerville Ma 02632 3-18-19 required for every 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 EQM Rr5M- TAYLOR DESIGN ASSOC., INC. SHEET NO. OF P.O. Box 1313 Forestdale, MA 02644 CALCULATED BY �� DATE 1'" 7C Tel./Fax: (508) 790-4686 / CHECKED BY DATE _. !• 07 v'b0.', 5 K,.v m C.o C ✓ 1u e.4SCALE A-4- M OF ....... ....._...... ............ ... ..�" ^ •.::. • i ........ ... ......... ......... .:............ .... ..... __.......... . ... ... ___... .... .. ..: U.4---mac: ..... .... ... ..___. .... .... .. ,l. - �-� , ,. r _ . ......... ................................ ......................... __..............................:....... ..... __ ..... ._ ..... .... . ..... ... 3fi° EQ tl.. 4 h t 1 ._4.... 4r ... .... ...�.. .... ... . B.............................. . ...... . .. `. .2..,, . _... _.. .... .:.... ........ .. .. ... f .. .. ..:. . - . .. .... ... . . ... . .. .... hoc or_ ... +r....: .. D ... . ..... .... ........ ... .... . . .�� ....... .. ...:.. ..... .......... .... ......... ...... ......... .: ...... �..�...... ...... .... ..... .. ...... .... ..... ...... 3 ....... .... ...... I 41; —415�Q� JOB QL TAYLOR DESIGN ASSOC., INC. SHEET No. of P.O. Box 1313 �`' Forestdale, MA 02644 CALCULATED BY E b DATE ZA Tel./Fax: (508) 790-4686 CHECKED BY DATE SCALE .. . ..... .._ 94 a .......... . A _`� .... ..... .. . .. ... . ... .;. ..°Z.7.a ..:. .. - . I� ... P e . . .. . 4. ... .:.. ... ;. :. �4.4 . ....... .:._ _._ .. ._...... __ ........ .... . .. xa®. � ..... JOB TAYLOR DESIGN ASSOC., INC. SHEET NO- of P.O. Box 1313 Forestdale, MA 02644 CALCULATEDR DATE Tel./Fax: (508) 790-4686 CHECKED BY DATE Lo-A%0 AI:> SCALE ............ ................ ....... .......... ........... ........... ...... ............ ...................................... ..............i........... . .. ......... ................... .......... ................. ............ ................ ................................... ........... ............. .............. ZeaC ............... ........... .................- ............... ....................... ................................ ........... ................ .. .......... ............ ......................... .............. .................. ...... .... ... ......... Pam ............. ...............................................- .............................. .......... 3. .......... .............. .............. .......................... ........... ..........................- ................................................................................................. t ........... .............. ...................... .......................... ................. .... ..... ............. ....... .......... ........................... .......... ......................... ....................... .................. ................. 0 lie, ..................... ...........................r-J-.--(:P ......................... ........... ...........................A.......................... ............ .............. ........ _0 ............- ..................... ........................................................................ .......... ............. .................................................. ............. ............................ .................. ............-- ........... ............ ............................. .............- ................ ..................... Le'r— ........... ............................ ............. ............. .............. .......... ..............: ..................... ........... .......... ---- --------- ........................- ........................ ................................................. ................................. Ica ...................... 7. .................... i......... ...... ................... --- ........... ............ ..................... .................................. .............. .............. .......... ............. ........... ............. .......... . .....it.......... .............. ..................... Di . . ........... .......... ............. .................................... ................... .......... .......... .......... ............... ..................... ........................................ .............. ...........-..........-..................... ................................. .............. .......... ......................................... ............ .. . ..... .... ................. ........... .......... .....................ue! .......... ........................... te ........... .................. .......................... ........................... ........... t............ ............. .............. ..... .............. .......... ...... p u*21-4mic.... ..... .......................................... d ................ ...................... ........... ......................................................................................... ............. ......... ............. ........... ...... 57 ovr- IV . ............................... 10 ........ .... I.................. ............................... ......................... .....................................................1 ................... ................... ........................................ ----------- ....... ............. .......... .................... A& too ........................... ....... ............. ...........v .............. ............. .................................................................. .... ................................................................................... ............. .............. ............ ........... ............. ........................................................... ....................... ............. .......... .................. ................................................................................ .... ......... ...............-.............................................. 'a 1'ev cvr AW ........... .................................................... ........................... .......... .............- ........... ...........................1...................................................-............. ........... .......... ....... .........................-- ..........................- .......... ................ .......... .......... .................................................................- ............. ................... .............. .......... .............- ..................... ...................... ....................... .............. .............. ............ .................................... ............ ..........- .......... .................. ............ ...........-................ .............. ........................ .............. ................1 ........................... .................................................... .......... ........... ............... ............................................... ............. ..................... ........... 0-................................................................... ........................ .......................... .............- .............d ................ No. god 0-7 `" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mie;pogar *pgtem Construction Permit Application fora Permit to Construct( )Repair( )Upgrade("/)Abandon( ) LI Complete System Rindividual Components Location Address or Lot No. O ner's Name,Address and Tel.No. Assessor's Map/Pazcel C e,� �v/� � � Installer's Name,Address,and Tel.No. ` C Designer's Name,Address and Tel.No. _ 7/ d'Z S Type of Building: _Dwelling No.of Bedrooms Lot Size Z ft. Garbage Grinder(/7�,�/�, Other Type of Building Pis G No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .230 gallons. Plan Date Number of sheets Revision Date Title tS Cp .S !"01- Size of Septic Tank f�5�� Type of S.A.S. Description of Soil 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 Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b thi Bo of Health. / Signed Date Application Approved by Date a yfiz Application Disapproved for the following reasons Permit No. QUO 3-07X Date Issued a 0 Ila J�t r. Fee TH 'G�O60" NWEALTH OF,WXSSACHUSETtTSt-�� Entered in computer: PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE., MASSACHUSETTS Yes 2pprication for Migpogal *pgtem Con' ruction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) LJ Complete System Andividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor'sMap/Pazcel C Installer's Name,Address,and Tel.No. 0 Designer's Name,Address and Tel.No. _ Type of Building: Dwelling No.of Bedrooms 'n Lot Size Z S 7�L q.ft. Garbage Grinder(/'e Other Type of Building P 4f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 5 30 gallons. Plan Date 7 ell03 Number of sheets / Revision Date Title LY 5;) If ✓0,01 Size of Septic Tank �;%:5��X Type of S.A.S. Description of Soil Nature of Repairs-or Alterations(Answer when applicable) 2�/, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi Board of Health. Signed Y tt Date z,szy/ ' Application Approved by I _ Date Y 61 Application Disapproved for the following reasons Permit No. A 0 3-07 X Date Issued Z )Y/o 3 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CEI% IFY, that t e Onn--site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ✓) Abandoned )by at l./ S �� /' 0# elJP11."'has been constructed in.accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. U � 20d?- 7.f dated Y 0 t Installer Designer The issuance of thi pe t shall not be construed as a guarantee that the system w' .tnct'on s de Date ��3 Inspector r --------------------------------------- No. 003_ 020 Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS &!6pogaf *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abando ( ) System located at C�lil 7`7�/-d✓i/fir' 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 thisMVDate: o�' �` 03 Approved by � . -�j� �2C ev )i 4-1 t/Uff 4 r p�r✓-UL, MI �Ov e 41, &r-(JJ-&IC^/ P r TOWN OF BARNSTABLE LOCATION —. 6r��l�s �� SEWAGE # � "O 7B VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC-TANK CAPACITY �S`ao 'tp c LEACHING FACILITY: (type) sco/=l «Q ��s �� (size) NO.OF BEDROOMS J BUILDER O �,OWNE PERMTTDATE: 0?/2;/a3 COMPLIANCE DATE: 3131,63 rc Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 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 Daw,1 r� IB I 3 O 1- L. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town 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: A. General Information When filling out rrr7�� forms the ( 1 computeto r,use 1. Inspector:, ` U only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 r"9tenance of.on sitie sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 340 ;I Title 5(310 CMR 15.000). The system: 4 ® Passes ❑ Conditionally Passes ❑ Fai[$ ❑ Needs Further Evaluation by the Local Approving Authority a .� w �—' 3/19/2010 ln'speW6r'hSig&aidrr 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. � zq t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sew a Disposal stem•Pa e 1 of 1701 D l _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 septic system is in proper working order at the present time. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (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 FIND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"'below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): " 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon tank,D-Box and two 500 gallon Chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No ,000 :109 Water meter readings, if available (last 2 years usage (gpd)): 2002008:10 ,000 Detail: 2008:297gpd. 2009:279gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , s 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed 2003 r detected when arriving at the site? Yes No Were sewage odors de ec g ❑ Building Sewer(locate on site plan): Depth below grade: 44"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 3' 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 gallon 4" Sludge depth: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 31- 5" 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 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be pumped within 1 year and every two years thereafter.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet lateral.Evidence of solids carryover.No evidence of leakage.Recommend Outlet cover of tank to be raised and a zabel filter installed in outlet tee to prevent solids carryover to leaching. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching chambers were dry at time of inspection.Stain line observed 18" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size . Zoom Out jIn ]I IC K T �cY•}•�.� �- r R. ily 1 JOF 1-4 15, L e } + `ct � k M YF 'Y O °o 0 20 et Set Scale 1" = 20 I I Aerial Photos I MAP DISCLAIMER (n—trinhf onnFAnlf)T—en nt Rornefohio KAA All rinhrc rocm— •._ _..1- _ _1.., lrnn 1/ nI Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. 02632 3/19/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Leaching 20' 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: 2/14/2003 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1153 Bumps River Rd. Property Address Nancy Pereira Owner Owner's Name information is required for Centerville Ma. J 02632 3/19/2010 every 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE C LOCA DON 646- � 6uAJDs SEWAGE #�U3"0-7B VILLAG ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Iroo cw L LEACHING FACILITY: (type) sow r.l L�w��•.r �� (size) NO. OF BEDROOMS BUILDER O OWNE PERMIT DATE COMPLIANCE DATE: 3 63 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5^ 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 Ja."I G;,oi G f 3 0 �a 7®. 7� �y it pu 33'-6" 20'-a ��-6• / oF s V la-O' ll( I q (a:°e•FI'FRAf 7IW PLAN) � � 0, .--� `'�p _Z > A �� L N�pT�p,o�pp{(� I wI cow e WAN� � � \i "'T Al vLt01 NE 9FRIEDR 8 ... _......_ 4'-0' o EXISTINGul I --�!CAtli 9®ilUt 3 a_ SCREEN PORCH I 3'-4' In (NO CHANGES) 4 I Q " ❑I PROPOSED REF. I DINING EXISTING D D PROPOSED FIRST FLOOR (� KITC44✓N (NO GIIANGES) o fil (am) A �-�- • p e--�-@ U 77------------ wil M&M.W.- o .-. --- ---- -------------- :.: ro PROPOSED o o LIVING ROOM s n EXISTING ( ) 2—CAR GARAGE - i e--------------�--- �eaterCAN=Sam e EXISTING IPORC e W ecAA V4p•rmm tY N 20-0' 6'-0' 30'-0" � 20-0' Ll o W RE-USE EXISTING 1 e✓4'X S 3/4' z CONTINUOi19 FUDGE 7 RE-USE EXISTING _0. V t'X 8 1/z" RE-USE DOSTING COLLAR TIES NEW ZO RILING 2 S/4'X II S/4• PRO11 EXIST11Yg 9'-0' 9'-0' I!- W RAPTHLS O O O.C. RAFTERS If 4D O.C. BATTS FIBERGLASS PER CODE 1a O' > u AT FVMkY z MW 31 X ) ATTIC SPACE �AT�E r 2�/ z ^^,, (�L 11 3/4•EXISTING 11 S/4'EXeSTMGF l¢- , ON SAT 4D" I'I 1'i I 1 RAF�AST o v + New z e COLING RE-WE PJISTING r——————————'I W JONST9®�•O.C. 2 J/4'X 11 3/V ,— J MSTRAPPING —.-- RAFPEM O4D O.C. -—————--—--- 0. y X —— LINE OF EXISTING CEILING —— ——— EMEND NTFRI018 J————— —————L L——— Z AS NEED FOR EIGHT r �—— 2'-O' CEILINGS To BE • • LL•e®_ ly�(2�)-P.T.2aas d ' W EXISTING 4 EXISTING I � :1 U W KITCHEN § f u L LIVING ROOM a Cz)-P.T.2IWS e O (ICAIe�Rlll. wi P.T.4(4 TO t2 g�q egg 1. ALL WINDOWS ARE TO BE REPLAGE:D 3N ITHANDERSEN 400 SERIES 3'-0" +/- � ♦gF-zs CBIG FOOT) II WINDOWS SIZED TO MATCH THE E�C15T13�tG ppENINCaS (5EE SCHEDULE) {.n Fe o � efi o CI 4'X Iz'FLOM JOISTS O 4s'O.C, 14e ® eyl ' IN tX18�T7P3G \—I S/4'X„E VY 4•AIRTSPACE r= i I b - v�'ii Nlr, rP. I e P.T. LECGER Tw. e I SHEET 2 OF LASW TYPICAL EXISTING CONC.SLAB 1 �\ cr1I DECK FRAMING PLAN I 28'-0' SCALE: 114" m 1'-0" PROPOSED CROSS SECTION f y SCALE: 1/4" - I'-O' I) : ' 11 T . PRAWN BY. F DATE: 10/0, 71_4. 11'-b' S7'-2. � r co u A EXISTING Dco ECK co 1—� 0 o o EXISTING V � 0 SCREEN PORCH (NO CHANGES) EXISTING o EXISTING J J KITCHEN Q pLd1NS LU L Q I III s u� REF. V _.., _. w. EXISTING 4 FIRST FLOOR � 4 (NO CHANGES) l--U V ro Bra = 3 FISTING o 9 EXISTING LIVING ROOM 2-CAR GARAGE c EXISTING ' 8 1�° PORCH A _ J EXISTING CONDITIONS FLOOR PLAN LU Ll SGALE. 1/4" m P-0" O 20'-0' G'-0' 30.-0. LU 261-0. co 1814.X coNrlN wtrJ RIDE I'o0x1J�R T� LU 0. z1(y�- A ` W Q r e LUJ Z 2�AATTIC SPAC 0 > J {L 5 _ MLIW..JOISTS a 24°O.C. 1 - - w 3 LU 10- EXISTING EXISTING D Ul J U4 KITCHEN LIVING ROOM (Q V LL- 14'-0' m Lo iv 4'X 12°FIAOR JOISTS a 45'O.C. 1 a/4'X ap In° 4°AIR SPACE _ . MaffTING WALLS +y 'RS T'P. _ O eh m 1 SHEET I OF 2 ti r EXISTING COW.SLAB y, 28-O' EXISTING CRO55 SECTION SGALE� 1/4" m I'-0" JOB: 1163 BR DRAWN 8Y:TFR DATE: 10/05/It