HomeMy WebLinkAbout0064 CAMP OPECHEE ROAD - Health 64 Camp Opechee Road
Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
V 64 CAMP OPECHEE RD t
Property Address } .
JUSTINE BEARSE �
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
—
page. City/Town State Zip Code Date of Inspection r"
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:out forms A. Inspector Information
filling out forms
on the computer,
use only the tab Christopher Maki
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services
use the return Company Name
key.
350 Main St.
r� Company Address
W Yarmouth MA 02673
City/Town State Zip Code
erw 508-775-2825 SI-14423
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
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,7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�r ,-P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
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:
SYSTEM IS IN WORKING CONDITION
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 acid if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ 'ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Ins
pection Form
_
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 CAMP OPECHEE RD
u
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
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 6pipe(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
f
Commonwealth of Massachusetts
IP Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated,wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All,Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
(5insp.aoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
64 CAMP OPECHEE RD
- Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded
El ® or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® 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
x _ Title 5 Official inspection Form
n I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t-
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
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 C:4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes-of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
,dimensions,depth of liquid, depth of sludge and depth of scum?
® ❑ 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)]
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
�. Commonwealth of Massachusetts
--- lip
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 16.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage '20 -79 GPD
g ( Y g (gpd))' 1.9-73 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: CURRENTDate
i5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
<v 64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
r
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):
l I
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000 GALLONSgallons
How was quantity pumped determined? TRUCK SITE GLASS
Reason for pumping: MAINTENANCE
t5insp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
N/A
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 12"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 1104
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY
PITCHED
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
6_4 CAMP 0_PE_CHEE RD
Property Address
JUSTINE_BEARSE _
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
6"
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: 1000 GALLONS
Sludge depth:
2°
Distance from top of sludge to bottom of outlet tee or baffle
f Scum thickness 211
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? ESTIMATED
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 GALLON TANK IN GOOD CONDITION. PVC TEE INLET AND CONCRETE OUTLET IN
PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 6" BELOW GRADE
15insp doc-rev 7/2612018 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
64 CAMP CIPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
15insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE—___ MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ �No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)-(locate on site plan):
Depth of liquid level above outlet invert EVEN
- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DISTRIBUTION BOX LEVEL AND WATERTIGHT
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
---- ---
-__=--Y Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
TTR- 64 CAMP OP_E_CHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order:. ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
i
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type: ,
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3-
INFILTRATORS
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t51nsp ooc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
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.):
3-INFILTRATORS FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids _
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp doc-rev 7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
.��_. __ `6�► Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
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
•
,5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
-- -_-,w� Title 5 Official Inspection Form
A);!� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 CAMP OPECHEE RD
Property Address
JUSTINE BEARSE
Owner Owner's Name
information is required for every CENTERVILLE MA 02632 12/11/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +10.5'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
TEST HOLE PERFORMED ONSITE SHOWED NO GROUNDWATER ENCOUNTERED AT 10.5'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�= 11� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�X
64 CAMP OPEC_H_EE RD
Property Address
JUSTINE_BEARSE
Owner Owner's Name
information is required for every CE_NTERVILLE_ MA 02632 12/11/2020
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 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
_!5-ns�aoc re, 7)2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
t
r
c�ID - (S�
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road `
iGM
Property Address �Ra
Elisabeth Helwig
r.
Owner Owner's Name '/
required for
is every Centerville V MA 02632 February 20, 2018
required for eve Y
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. General Information Sly �a�uga—
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Jason C. Ellis
use the return Name of Inspector
key.
J.C. Ellis Design Co. Inc.
Q Company Name
P.O. Box 81
Company Address
North Eastham MA 02651
CitylTown State Zip Code
(508) 240-2220 SI 3600 IRS 1126
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
❑ Ne ,u hers luation by the Local Approving Authority
ON cy
G
Ifo' f'tIS ER
February 20, 2018
Ins p ok ss Ignatere- Date
.S T `yG
The s e sp RIQ all submit a copy of this inspection report to the Approving Authority(Board
of Healt On
in 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.
l5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17
/,Dc�yu VS
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in satisfactory condition at time of inspection. Septic tank should be pumped soon.
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every eruar y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1lY2 day flow
t5ins•3/13 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 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every y
page. Cityffown 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: 0.
❑ ® 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.]
❑ Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15:303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems; you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within'400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
requinform
r on is Centerville MA 02632 February20, 2018
requiredd for every ery
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): N/A Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
ti F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d '17-47 gpd, '16-
9 ( Y 9. (gpd)): 61 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for 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: BOH
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 64 Camp Opechee Road
Property Address
Elisabeth Helw_ig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
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:
1993 - Permit at 60H
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
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.):
Satisfactory condition
Septic Tank (locate on site plan):
Depth below grade: 0.75'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
12"
t5ins•3/13 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
64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every y
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
22"
Scum thickness 12
Distance from top of scum to top of outlet tee or baffle 6„
Distance from bottom of scum to bottom of outlet tee or baffle
2"
How were dimensions determined? Direct observation -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.):
Septic tank was in satisfactory condition at time of inspection. Inlet 10" below grade; Outlet 7" below
grade. Septic tank should be pumped soon.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is required for every Centerville MA 02632 February 20, 2018
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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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 in satisfactory condition -8" below grade. Broken lid was replaced.
I
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title. 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M e' 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
SAS was in satisfactory condition at time of inspection - Dry at time of inspection. Plastic chambers
24" below grade. No evidence of failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every y
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
` Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
A 43
1785
Z7.5 ' 26
As.
3Z. s
3
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 64 Camp Opechee Road
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every Y
page. CitylTown 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: 4'+ below leach area
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database -explain:
USGS topo and groundwater contour maps
You must describe how you established the high ground water elevation:
Groundwater level in this area is 4'+ below SAS
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 64 Camp Opechee Road
M
Property Address
Elisabeth Helwig
Owner Owner's Name
information is Centerville MA 02632 February 20, 2018
required for every y
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
McKean, Thomas
From: McKean, Thomas
Sent: Friday, January 17, 2014 11:26 AM
To: Dabkowski, Cindy
Subject: Septic Questionnaire/64 Camp Opeechee Rioad Centerville/ Helwig
Good Morning,
Thee submitted floor plan for 64 Camp Opeechee Road shows three bedrooms plus an unlabeled room adjacent to
the living room.
Please describe the use of this unlabeled room.
1
S
Town of Barnstable Health Inspector
F1t+E T Regulatory Services Office Hours
o °�ti g Y 8:30—9:30
o„ Thomas F.Geiler,Director 3:30—4:30
SrAB . : Public Health Division
MASS.
A i639' `0� Thomas McKean,Director
QED MA'S A
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
Date:November 18,2013
1. General Information: Size of Property.75 acre
Address:*64 Camp Opechee Road Centerville,MA 02632 Map 210 Parcel 151
Name: Elisabeth A Helwig Phone#: 508-534-9735
2a. How many bedrooms exist at your property now?2
2b. Are you planning to add any bedrooms?Yes If yes,how many? 1
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer, skip questions#4 through#9 below.
4. Location of dwelling is Outside a Saltwater Estuary Protection Zone?
5 . Location of dwelling is Outside a Zone of Contribution to public supply wells?
`l
6. Is the dwelling connected to an PUBLIC WATER? �
IV)
7. Is a disposal works construction permit on file? NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 10
9. Were any building permits obtained for construction of additional bedrooms? YES or NO p
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to' bedrooms at this property.
Special Conditions:
Signed: Date: &LIllq
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CERTIFICATION
I CERTIFY TO THE ABOVE ATTORNEY,BANK,AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR
DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO
STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL
LAW TITLE VII,CHAPTER 40A,SECTION 7.
PLEASE NOTE:ALSO DEED BOOK 532 PG.300[']
NOTE:LOT CONFIGURATION IS BASED ON DEED, AND/OR ASSESSOR'S MAP&OCCUPATION. A MORE ACCURATE REPRESENTATION
WILL REQUIRE AN INSTRUMENT SURVEY.
FLOOD DETERMINATION
BY SCALE,THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF
COMMUNITY#2500010005C AS ZONE C DATED 8-19-85 BY THE NATIONAL FLOOD INSURANCE PROGRAM.
Of
fi" �tJ' cf
Olde Stone Plot Plan Service Co. o NE,
P.O. Box 1166 KELLY m
s=� Lakeville, MA 02347- NO. 36036
Tel: (800) 993-3302
Fax: (800) 993-3304
PLEASE NOTE: This inspection is not the result of an instrument survey.The structures as shown are approximat nly. An ins tru nt survey
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t
Town of Barnstable Health Inspector
FTHE T Regulatory Services Office Hours
t
0 oiyti _ g Y 8:30—9:30
o� Thomas F.Geiler,Director 3:30—4:30
BM
MrAs , : Public Health Division
9�p 1639• A�e� Thomas McKean,Director
rFD MP'I
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM.APPLICANT- SEP.TIC QUESTIONNAIRE
Date: October 17,2012
1. General Information: Size of Property.75 acre
Address:64 Camp Opechee Road Centerville,MA 026321 Map 210 Parcel 151
Name:Elisabeth A.Helwig Phone#: 508-534-9735
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms?Yes If yes,how many? 1
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?2.
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is Outside a Saltwater Estuary Protection Zone?
5 . Location of dwelling is Outside a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an PUBLIC WATER?
7. Is a disposal works construction permit on file? NO
8. If yes,how many.bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES zofi NO
10. Is there an engineered septic system plan on file at the Health Division? YES ':or NO
I L Has the septic system been inspected by a DEP certified inspector within the last two years? YES N'or NO
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date:
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1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5
required for , 2009
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 A. General Information
forms on the
computer, use
only the tab key 1. Inspector:
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name �
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894 1328
Telephone Number License Number
B. Certification
I certify that I have per-sonally 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.D—E , proved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes A-❑ Conditionally Passes ❑ Fails
q o z
❑ Needs Further Evaluation by the Local Approving Authority "
�s
October 5, 2009
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Aut tRr ty Mard
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:SubsurfAisp
osal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if the
inspector cannot answer Yes to any of the failure criteria listed in Section D on pages 4-5 of this
report. The septic system has been evaluated according to the conditions observed on the day it was
inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5 2009
required for ,
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 ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5, 2009
every page. CitylTown 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 '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5 2009
required for ,
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5, 2009
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: — 1 �``�.
n/aF 2 assr
Number of bedrooms (desi n): ✓Number of bedro ms (actual):
DESIGN flow based on 310 CMR 15.203 example: 110 gpd x#of bedrooms): - no plan
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 8 gpd
9 ( Y 9 (gpd))
Detail:
2007-2008
Sump pump? ❑ Yes ® No
Last date of occupancy: undetermined
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°w 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5 2009
required for ,
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:
Age unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank(locate on site plan):
Depth below grade: 0.5feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8.5ftx5ftx5ft(1000gallon)
Sludge depth: 4 in
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
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 30 in
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Previous inspection report
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
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
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
every page. CitylTown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts.
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 64 Camp p O echee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at 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.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump.
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•09108 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 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5, 2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into
the distribution box and was observed to pass through in a rapid and unobstructed manner, and could
be heard splashing down.
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
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
4
z iu31
�-_❑
- �y
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System .Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is required for Centerville MA 02632 October 5 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
.If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Town of Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 20 feet above
groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 64 Camp Opechee Road
Property Address
Stacey Spell and Jefferey Hautanen
Owner Owner's Name
information is Centerville MA 02632 October 5 2009
required for ,
every page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t
451
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH APPROVED
TOWN OF B A R N ST A B L E Comm Conservation Department
Appliratiou for Diripooal Worko Town
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...........&Y..... ... _. ........
r--
��J _�..�_�.....�or�:ion•:�c d •ss ..__-^------....or•Lot-No:
.....__...!!....lil»` `Y�� 1 ___^ ........................... •....................•... .__._..-..._...-................................
Owner Add s �
Installer Address
-
UType of Building Size Lot...........................Sq. feet
,., Dwelling—No. of Bedrooms-------------------------------------------Lxpansion Attic ( ) Garbage Grinder ( )
aOther—Type of Buildin - -- --� No. of persons Showers (�) — Cafeteria ( )
dOther fixtures .......••-••-•--•-------------•-•..._........-•---••----•----------------------..... ..........................•••••-------•-•-----•---••--•--•----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity Z0!P....gallons Length................ Width--------------.- Diameter---------------- Depth................
x Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet..--................ Total leaching area..................sq. ft.
Z Other Distribution box ( i ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
1.4 Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..--....................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 .....----••--•--------------•---•-•-•---••-•---••-••••---•-•-•••••••------------•--------------•---------------.._..---......_•------...........
----..........
ODescription of Soil-------•---------------------------------------------------------•-----•--•---------•----•--•------------•-•-------•--...------------------------------.........-_•-•••.
W
V .........•••••••--••---•----•••••••••--•••••----•-------•---•---•--••-----•--•-••---•••-••--••-•--•••------•-•---•------•----•••------•-•----•----•-------••••-----•-=•-..........-•••••------------•-•--
W
UNature of Repairs or Alterations—Answer when applicable....-...........................................................................................
-•-•-•........•---••---•••••-•--------•-•-•--•-----------•-...-•-••----•••......................•----•--••-----••-••••-------•--•---•-••---•----•--•••--••••---••---•---•-•----•-•-----.............--•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian as been issued by the board of health.
Signed ......... . .. ........... &--e2 9.-..F-�.:...........-""" -"-"-...
Application Approved By ... .... ......� . ��'.G�
--....--------- —. ...._........................ Dace
Application Disapproved for the following reason -- ------------------------------------------ -----
........................ ... ......................................... . "-"""".................................
�......................"% --
Permit No. .. °may s�
... Issued .... ..�� ...:.`.....J
Dare
1
} yam,. .•y��.y-i -, rG x ......r. zy�� >:V-,,,.•�1...-fir _. �F _ .@__, .W .._ �. ...� __... _• ._._____.__._.. _ _
No.. > ... 1�� Fr s.. :._ram
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
A lirativit for Di�� wial Works-C�owitrar"tu- r`ramit -� �'
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Lo ddressIon :\c: or Lot No.
Oar ner Addr ss
a _.._'� �s ��✓•----------------------- -•.._.. �2�G_�/_r'� - -g '�'"�.�.
/ 1 Installer Address
UType of Building Size Lot............................Sq. feet
.� Dwelling—No. of Bedrooms-.-----_----o�-------- -----------_---Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Buildin�� No. of persons-----02................. Showers Cafeteria ( )
a' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow...........................................-gallons.
WSeptic Tank—Liquid capacityeWq.._gallons Length---------------- Width---------------- Diameter--------.---.--- Depth................
x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area............-.......sq. ft.
3 Seepage Pit No..................... Diameter..---...----...--... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( 1 ) Dosing tank ( )
Percolation Test Results Performed by
a ---------------- ......................................................... Date...............................t-..
a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..---.------............
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .....----•-....•----------------•--.......-•--•-•------••--•-••--•................-••--------••-••----................-----................................•.
0 Description of Soil................................................................................................................................................. ......................
W
U •------------------•----...-----•--.....------------•-•----------------------------------•----•-------------------------.•..----•----------•-------•----•------------•--.............------......_----•-
W
--•••••••-•......-•••--••.•-------•-•---••-•-•---•-.....•••-----------------------•••----•---------------------...........--...----••.....•-------••--•--------•••-••---•-•••---•----•-•-••--•---_.....
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement: _
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as been issued by the board of health.
Signed ..--..-� I. - - .-.-.5 .:.-....
- � U Da�
Application Approved By - 4 .� J.Y �� -
'3^'p j.....-----...---- -- --...---------- - - ........................................ ..-------Dace .,,�:...-a1...
Application Disapproved for the following reasons- -------------------------------------------
- ......-................................ . -- -. -----------.......... ......... -------- ........"......�. --------------......
-....
-....
-.....
..
Permit .......... Issued ------ ..."... ...... .::3 I
/ Due
- ---- -a-----_—.mar.-.=:=:ary ---h.---.s----.�,-
_>em+rc-�:�a-,.a��-����1.,�...•:..:,r=s-:�,.-:�-,��:.:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH l
TOWN OF BARNSTABLE
(ILI-Prtifirate of C omplittnre
THIS LS�T0 CERT Y T at the Indiv;dual Sewage Disposal System constructed ( ) or Repaired ( �)
by /� /Urt t .............................._......................................
at .................(,,..4�..........C� O�-ef>l���.....- � .....-.. _.....-. . f �--- -------Via..— -----------------
has been installed in accoedance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. - .-.., ..f � -.. dated ...��
THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUEID AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
j ' .........................................
DATE............ ............................� �'. ... j--------......... Inspector --.-. . t 1 ..'`. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
i FEE..............:.
No.. .......... � �
Bispooal Workii Tonotrurttinn "pamit
Permissionis hereby granted----------------------------------------------'--------------------------------•---•---------------------------------------------•-•--------•-
to Construct ( ) or Repair (p,)' an Individua Sewage Disposal System
at No....-... ------ `2--._/Z.._.j&,- --- ; 1 .----- �r�;��1 -�12 `-----•---- -------------------------------•--
Street
as shown on the application for Disposal Works Construction P/er/mi�tN ---/ - ^ .
�. J/ �...s" ���B�iFd�of�He�lth•'� ''� L
DATE -----------•---•-------
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION G EcAe•P SEWAGE # q3 l �
VILLAGE 6xiP",-11 /1`/le ASSESSOR'S MAP & LOT / I
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /0 0 o (;Aj-
LEACHING FACILITY:(type) 3- %/Ka ����(size) ,CS
NO. OF BEDROOMS -2 PRIVATE WELL OR PUBLIC WATER -r- �c?AJ
BUILDER OR OWNER
DATE PERMIT ISSUED:DATE COMPLIANCE ISSUED: /31
P
~
VARIANCE GRANTED: Yes No �/
roc 0 f
1 aUs