HomeMy WebLinkAbout0204 CAP'N CROSBY ROAD - Health LA
04 Cap'n Crosby Road
= 193 -210
Centerville
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S M E A D
No.H163OR
UPC 10259
smead.com • Made in USA
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
';Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capn Crosby Road
Property Address -°
William &Judith Jollimore t�
Owner Owner's Name c?
information is required for every Centerville ✓ MA 02632 3-15-19 T'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.
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1.
Important:When A. Inspector Information �/# /3�s-� �°�� . "' sq�y,;
fillip out forms
on the computer, `��:' DAMES G
use only the tab James D.Sears S m
key to move your Name of Inspector Co =
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use the return Capewide Enterprises �,• o
key. Company Name 'ii� ? fF�
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l�-6 Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S 1623
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
3-15-19
spector'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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.0 204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is
required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
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 is a 1000 Gal Tank D Box and Pit.
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ 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
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�!%F 204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in NNEW is less than 6" below invert or available volume is less
than '/z day flow Po r
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed (
ipe s). Number of times pumped:
P
❑ ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal. Tank D Box and Pit.
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2017-96,000Gals
g Y g �gp ��' 2018-53,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PresentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
�V
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
r
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil Y
absorption system
P
❑ 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:
1979 Permit # 79 -621 /3-2019 New D Box Line Repair
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 4'-2"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
<I�n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 40"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Plan-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 40" below grade w/both cover's at 15... In and outlet tee's. No
sign of leak age or over loading.
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
emu,
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is Centerville MA 02632 3-15-19
required for every
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
" Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-43" below gade w/cover at 8". Box is New 3-2019 w/one line out
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit . 30"water in pit. Note: Pipeing to pit is piped into riser w/cover
at 1'. No sign of over loading.
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.):
15insp.doc•rev.7/26/2018 Title 5 Official InspecUon Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
- : Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
emu,
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Owner Owner's Name --------------_----- !--
information is Centerville MA 02632
required for —
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Ca 'n CrosbY Road
Water
Service
. . . . . . .
r / /
. . . . . . . . .. .
31
19
9
20 87
47
c ., Commonwealth of Massachusetts
Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 204 Capn Crosby Road
V Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
�o
Estimated depth to�high ground water: fee
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. 9-4-79
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 9-4-79 18' no G.W.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
,o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capn Crosby Road
Property Address
William &Judith Jollimore
Owner Owner's Name
information is required for every Centerville MA 02632 3-15-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE !�
LOCATION -1 f Ct S�#,,nS
VILLAGE ��rV ►�� SESSOR'S MAP&PARCEL
III NAME&PHONE NO. r,t k A,40 ( L( 11�q
SEPTIC TANK CAPACITY I()CQ
LEACHING FACILITY:(type)�I (size) ICCO
NO.OF BEDROOMS
OWNER WOCJ 0C, K
PERMIT DATE: CMVfft;h�E DATE"1�7 05
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leachin Facility(If any wetlands exist within
300 feet of leac ' g facility) Feet
e- FURNISHED BY 0
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47
No. ��� �� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpfication for Disposal *pstem (Construction Permit
Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. ;14t4 ! [ C4 R c r,y Rr) Owner's Name,Address and Tel No.
C'�r« tW ILc,i�tK+1 vbc?H tort-t IKDt�c=
Assessor's Map/Parcel 1 a i 6-r nuNS C A c.4
Installer's Name,Address,and Tel.No. 50 8—q"t 1—W77 Designer's Name,Address,and Tel.No.
CA9�cilcOcS F.1�TERP�ISe—S l
� A
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Vp /
Design Flow(min.required) / gpd Design flow provided /V gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) i-iJ SQL AVEyo H-do D Cu ad R_l5ER�
C 4&Q GE6 1_wsF AS N A-" FCC
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal 2
Si Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit NO. �� (� �� Date Issued
No. [' �(` I Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 's
ftplication for Misposal Opstem Construction permit
Application for a Permit to Construct( ) Repair(Q Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. act jAp� CRd5Sy RD Owner's Name,Address,and Tel.No. _
Assessor's Map/Parcel aZ 1 C��t W"`tA� +SvDvrfUr Sr z u'����
Installer's Name,Address,and Tel.No. sOE-q'l 7—1277 Designer's Name,Address,and Tel.No.
�.A��t+►.�rp�a �TERPRtS�S f RI3p NIA
L 5 C P
Type of Building: /)
Dwelling No.of Bedrooms W / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building" No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) /y gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) J-i.]S l k _ A*-x 2 N'
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health,22
Signed Date J 1�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 2 ZS 10j � 7 " Date Issued
--------------------------------------------------------------------------------------------------------------------------- -----------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired X) Upgraded( )
Abandoned( )by—eA
Del o i o 6� �� I;Ct �— �
at a04 CAP,kJ V Rn e-±'Ul/GL6: has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.R01 — O��'dated
Installer Designer ( /-
#bedrooms Al k Approved design flow AJ Y' gpd
The issuance of this permit shall not be construed as a guarantee that the system will f u6ion'as desig iia
Date �i// l/ Inspector —,r,
------------------------------------------------------------------------------------------------------------------------------------------
No, d ( — O Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
�isosal *pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at 304k ,tea J (29Z_raS V Qb
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.._---"--
Date ?j'' /2—'Q Approved by
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby -
Property Address
Jerry Epstein
Owner Owner's Name
information is Centerville MA 02632 June 10, 2012
required for
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the U
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co
Company Name
reb 189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508-428-1779 SI 12855
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
eeds Further Evalua " n by the Local Approving Authority
untie 10, 2012 Job# 12-91
Ins ctor's Signal ure 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.
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Lo�(e •zJ zzo
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is Centerville MA 02632 June 10, 2012
required for
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:
Tank was pumped following inspection leaching pit was found empty with no signs of surcharge.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 -Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Capin Crosby -
Property Address
Jerry Epstein
Owner Owner's Name
information is Centerville MA 02632 June 10, 2012
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 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.
12.91 Epstein 204 Ca-rn Cr.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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_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.
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is Centerville
required for MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
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)]
12-91 Epstein 204 Cap'n Cr.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityfrown State Zip Code Date of Inspection
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
Number of current residents:
1
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 d N/A irrigation
g ( y g (gpd))-. system.
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied.
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:
Last date of occupancy/use: Date
Other(describe):
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Unknown
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
12-91 Epstein 204 Cap'n Cr.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 4
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain).-
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan).-
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-------------------------------------------`------------------------------------------------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 26
4"
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 101,
How were dimensions determined? Measured
12-91 Epstein 204 Cap'n Cr.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown 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.):
Liquid level was found at bottom of outlet invert, tees are intact and clear. Tank was pumped
following inspection.
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.):
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):
12.91 Epstein 204 Cap'n Cr.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title S Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No solids or high stains present, liquid level at bottom of single outlet pipe.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
12-91 Epstein 204 Cap'n Cr.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number:
One 6x6 pit.
❑ 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.):
Leaching pit was empty at time of inspection with no evidence of hydraulic failure.
12-91 Epstein 204 Cap'n Cr.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
12-91 Epstein 204 Cap'n Cr.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5' Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
204 Cap'n Crosby -- -- - -
Property Address
Jerry Epstein — --
Owner Owner's Name
information is Centerville MA _ 02632 _ June 10, 2012
required for --- -------- -- -- - State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Ca 'n CrosbY Road
Water
Service
31 " \
19
59
47 20 87
r
• Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Jerry Epstein
Owner Owner's Name
information is required for Centerville MA 02632 June 10, 2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to 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: 9/4/79
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:
Perc test performed on 5/11/79 found no water at 18 feet.
12-91 Epstein 204 Cap'n Cr.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Commonweal 11 of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewi a Disposal System Form -Not for Voluntary Assessments
204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is
required for Centerville _ MA 02632 September 2, 2009
every page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
W
forms the
computer,
r,use 1, Inspector: h1
only the tab key
to move your Patrick M. O'Connell
cursor-do not use the return Name of Inspector
key. Septic Inspecti n Services Co.
Company Name
r� 189 Cammett ad
Company Address
Marstons Mills MA 02648
CitylTown State
Zip Code
508-428-1779 SI 12855
Telephone Number License Number
B. Certificaticin M \ o-
4.mF' T
' f
I certify that I have rsonally inspected the sewage disposal system at this address' nd that thR
information reported below is true, accurate and complete as of the time of the inspe,tion. The peen
was performed bas on my training and experience in the proper function and maintenance o n s1 Ln
sewage disposal sy .ems. I am a DEP approved system inspector pursuant to Se Dtion 15.W0 of,
Title 5 (310 CMR 'I 000). The system:
C0 rn
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furth,'r Evaluation by the Local Approving Authority
September 2, 2009
Ins ctor's SignaturE Date
The system insp otor shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP I`within 30 days of completing this inspection. If the system is a shared system or
has a design flOm of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the app priate regional office of the DEP. The original should be sent to the system owner
and copies sent t the buyer, if applicable, and the approving authority.
****This report only jescribes conditions at the time of inspection and under the conditions of use
at that time. Thisi inspection does not address how the system will perform in the future under
the same or diff rent conditions of use.
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage D osal System Pa()e 1 of 5
8
Commonweall i of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments
*M 204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is
required for Centerville MA 02632 September 2, 2009
every page. Cityfrown State Zip Code
Date of Inspection
B. Certificati , n (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not lound 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 b E low.
Comments:
Tank is not inn ed of pumping at this time, leaching pit was found empty with no signs of surcharge.
B) System Condillonally Passes:
❑ One or mom 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 o Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," pl i se explain.
❑ The septic t nk is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally I nsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will lass inspection if the existing tank is replaced with a complying septic tank as
approved b the Board of Health.
*A metals tic tank will pass inspection if it is structurally sound, not leaking and if a Certificate,
of Complian a indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or bbstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspect on if(with approval of Board of Health):
❑ brok n pipe(s) are replaced
❑ obst iction is removed
09.168 WOODLOCK.doc-08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form - Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville required for MA 02632 September 2, 2009
every page. City/Town State Zip Code Date of Inspection
B. Certificati bn (cont.)
B) System C e nditionally Passes (cont.):
❑ diE I ribution box is leveled or replaced
ND Explain:
❑ The systerr required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will ass inspection if(with approval of the Board of Health):
brcten pipe(s) are replaced
❑ ob ruction is removed
ND Explain:
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 i failing to protect public health, safety or the environment.
1. System Vill pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b i that the system is not functioning in a manner which will protect public health,
safety and ie environment:
❑ Ces pool or privy is within 50 feet of a surface water
❑ Ces pool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and vironment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 ' et of a surface water supply or tributary to a surface water supply.
❑ The ystern has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supr Y.
❑ The ystem has a septic tank and SAS and the SAS is within 50 feet of a private water
supr y well.
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r
Commonweal h of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sew, a Disposal System Form -Not for Voluntary Assessments
•� ••'y 204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. CitylTown State Zip Code Date of Inspection
B. Certificat n (cont.)
C) Further Evalu ition is Required by the Board of Health (cont.):
❑ The syster i has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from private water supply well".
Method us d to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for colifortn
bacteria indica s absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 pp 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 indi to "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 water:,
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than_day flow
❑ ® 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.
09-168 WOODLOCK.doc-08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonweali i of Massachusetts
Title 5 CIfficial Inspection Form
Subsurface Sewa e Disposal System Form -Not for Voluntary Assessments
204 Cap'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville required for MA 02632 September 2, 2009
every page. Citylrown State Zip Code Date of Inspection
B. Certificati n (cont.)
D) System Failuri Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 systery 5, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Sec ion 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 ans red "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 consider cl a significant threat under Section E or failed under Section D shall upgrade the
system in accord 'nce with 310 CMR 15.304. The system owner should contact the appropriate
regional office of he Department.
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonweall I of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments
204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is
required for Centerville MA 02632 September 2, 2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the fol wing 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)]
09-168 WOODLOCK.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sew ge Disposal System Form -Not for Voluntary Assessments
w 204 Cap'n Crosby
Property Address
Charles Woodloc
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Ir formation
Residential FI bw Conditions:
Number of bed ooms (design): 3 Number of bedrooms (actual):
3
DESIGN flow t ased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of curr ent residents: 0
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a eparate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry systent inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ !No
Water meter readings, if available(last 2 years usage (gpd)): —
Sump pump?
❑ Yes ® No
Last date of occ i ipancy: Unknown
Date
Commercial/In t ustrial Flow Conditions:
Type of Establis ment:
Design flow (basad on 310 CMR 15.203): _
Gallons per day(gpd)
Basis of design ow (seats/persons/sq.ft., etc.): _
Grease trap pre nt? ❑ Yes ❑ No
Industrial waste olding tank present? ❑ Yes ❑ No
Non-sanitary wa fle discharged to the Title 5 system? ❑ Yes ❑ No
Water meter rea ings, if available:
Last date of OCCL pancy/use:
Date —
Other(describe)
i
j 09-168 WOODLOCK.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
i
i
Commonweal h of Massachusetts
: Title 5 Official Inspection Form
s Subsurface Sew a Disposal System Form - Not for Voluntary Assessments
204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is
required for Centerville _ MA 02632 September 2, 2009
every page. Citylrown State Zip Code Date of Inspection
D. System Ir formation (cont.)
General Information
Pumping Records:
Source of infor ation: Unknown
Was system p ped as part of the inspection? ❑ Yes ® No
If yes, volume umped:
gallons
How was quan ty pumped determined? _
Reason for pun,ping:
Type of Syste
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
i ❑ Overflow cesspool
❑ Privy
❑ hared system (yes or no) (if yes, attach previous inspection records, if any)
Elnnovative/Alternative technology. Attach a copy of the current operation and
aintenance contract (to be obtained from system owner)
❑ right tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1979
Were sewage oc ors detected when arriving at the site? El Yes ® No
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonweal h of Massachusetts
Title 5 fficial Inspection Form
Subsurface Sew a Disposal System Form -Not for Voluntary Assessments
°w 204 Cap'n Crosby_
Property Address
Charles Woodlock
Owner Owner's Name
information is
required for Centerville MA 02632 September 2, 2009
every page. City/Town State Zip Code Date of Inspection
D.,System In t ormation (cost.)
Building Sew r(locate on site plan):
Depth below g de: 4'
feet
Material of con truction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below gr de:
3'
feet
Material of conE ruction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other(explain)
If tank is metal, st age:
years
Is age confirme by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------------------------------------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
3"
Distance from to of sludge to bottom of outlet tee or baffle 27"
_
Scum thickness
2"
Distance from to of scum to top of outlet tee or baffle
6"
12"
Distance from bc tom of scum to bottom of outlet tee or baffle —
How were dimen� ions determined? Measured
09-168 WOODLOCK.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonweali i of Massachusetts
Title 5 Clifficial Inspection Form
Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments
M 204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. Citylrown State Zip Code Date of Inspection
D. System In ormation (cont.)
Comments (on Dumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as elated to outlet invert, evidence of leakage, etc.):
Liquid level wa found at bottom of outlet invert, tees are intact and clear. Tank is not in need of
pumping at this time.
Grease Trap (I cate on site plan):
Depth below gr de:
feet
Material of con ruction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other(explain):
Dimensions:
Scum thickness
Distance from t of scum to top of outlet tee or baffle
Distance from b ttom of scum to bottom of outlet tee or baffle
Date of last purr ing: _
Date
Comments (on j lumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as r lated 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 gra e: _
Material of cons uction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other(explaih):
09.168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form - Not for Voluntary Assessments
M 204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. Cityfrown State Zip Code Date of Inspection-
D. System Information (cont.)
Tight or Holdi g Tank (cont.)
Dimensions:
Capacity: _
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order ❑ Yes ❑ No
Date of last pur ping: Date
Comments (cor Jition of alarm and float switches, etc.):
"Attach copy o urrent pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution 6 (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
1.
Comments (notl if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leak i ige into or out of box, etc.):
No solids or hig stains present, liquid level at bottom of single outlet pipe.
Pump Chambe (locate on site plan):
Pumps in workin order: ❑ Yes ❑ No
Alarms in workinl order: ❑ Yes ❑ No
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonweal h of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewz ye Disposal System form -Not for Voluntary Assessments
204 Ca 'n Crosby
Property Address
Charles Woodlock
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. Cityfrown State Zip Code Date of Inspection
D. System 1formation (cont.)
Comments (no e condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorpti System (SAS) (locate on site plan, excavation not required):
If SAS not loca ed, explain why:
Type:
® leaching pits number: One 6x6 pit. —
❑ 1 aching chambers number: —
❑ I aching galleries number: —
❑ lizaching trenches number, length:
❑ I aching fields number, dimensions: —
❑ erflow cesspool number: —
❑ ii i novative/alternative system
ilype/name of technology:
Comments (nOtE condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.)
Leaching pit wac empty at time of inspection with no evidence of hydraulic failure.
09-168 WOODLOCK.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonweal h of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sew a Disposal System Form - Not for Voluntary Assessments
204 Ca 'n Crosb
Property Address
Charles Woodlock
Owner Owner's Name
information is p
required for Centerville MA 02632 September 2, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Ir formation (cont.)
Cesspools (cf 3spool must be pumped as part of inspection) (locate on site plan):
Number and c nfiguration
Depth—top of quid to inlet invert
Depth of solids layer
Depth of scum yer
Dimensions of esspool —
Materials of coi I struction
Indication of gr undwater inflow ❑ Yes ❑ No
Comments (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate or'site plan):
Materials of con truction: —
Dimensions —
Depth of solids —
Comments (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
I
i
i
I
09-168 WOODLOCK.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwea th of Massachusetts
Title 5 Official Inspection Form
Subsurface Sew ge Disposal System Form - Not for Voluntary Assessments
w„ 204 Ca 'n Crosb
Property Address
Charles Woodloc _
Owner -- ----._...._----...---
Owner's Name
information is required for Centerville MA 02632 September 2, 2009
---- -----------------------
every page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sev,3ge Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where ublic water supply enters the building.
Ca 'n CrosbY Road
Water
Service
\ \ \ \ \ \ \ \ \ \ \
31
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \
\ \ \ \ \ \ \ \ \ \
19
w
` 9
20 87
47
i
I
i
I
i
f. Commonweal h of Massachusetts
Title 5 fficial Inspection Form
Subsurface Sew, a Disposal System Form - Not for Voluntary Assessments
204 Ca 'n Crosby
Property Address
Charles Woodloc
Owner Owner's Name
information is Centerville
required for MA 02632 September 2, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Ir formation (cont.)
Site Exam:
® Check Slo e
® Surface wt ter
® Check cell r
® Shallow Alls
20+
Estimated dep i to ground water: feet
Please indicatE all methods used to determine the high ground water elevation:
® O ained from system design plans on record
If ecked, date of design plan reviewed: 9/4/79
Date
❑ Otterved site (abutting property/observation hole within 150 feet of SAS)
❑ Ch cked with local Board of Health -explain:
❑ Ch cked with local excavators, installers - (attach documentation)
❑ Ac essed USGS database-explain:
You must desc ibe how you established the high ground water elevation:
Perc test perfor ied on 5/11/79 found no water at 18 feet.
09-168 WOODLOCK.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 15
No........................o ................
_.
THE COMMONWEALTH OF MASSACHUSETTS
a D `f BOAR® OF HEALTH
e �� � ...---Town.....................................OF..........Barnstable...............................................
Appliratinn for Uispm al Works Tnnitrnrtinn ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # 58 Ca 'n Crosby Road - Centerville,_ MA _ 02632
.. __. ......... ... .......... ................
Location-Address or Lot No.
... ZUsf.-•.................................. ........... ..................
Owner Address
W Kevin Hickey----•-••..---- •-------•- .........72--C-arr 0ge L�n�...$arll�tabl,
Installer Address 36,488
Type of Building] Size Lot............................Sq. feet
DwellingTNo. of Bedrooms.............thre2 _ __ ._Expansion Attic (no) Garbage Grinder (no)
PL4Other—T e of Buildin !finch No. of persons............t.W0........ Showers 2 — Cafeteria no
W Other fixtures .-----•----•---••------------•-----•------•---••-
W Design Flow.............1.10......................gallons per person per day. Total daily flow.............33.Q.......................gallons.
WSeptic Tank—Liquid'capacity..I.M.Wallons Length................ Width................ Diameter-----.--........ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X) Dosing tank ( )
'-' Percolation Test Results Performed by...................Ronald_Gifford.............. Date...May__11......1979-.
Test Pit No. 1._-._.?_..--..minutes per inch Depth of Test Pit....21.�........ Depth to ground water........................
04 Test Pit No. 2....... ......minutes er inch Depth of Test Pit..-_�.$.......... Depth to ground water--- ....
a #1 --•------ -.---1�.5•�•--•---•lo ....ub o .l... ....cl ay.-•--•Q 12'5'...same......#1=2...--
O Description of Soil.................. 0.5'.-21- ----.f lne..dOnee---nand--------------------12..5..,=j- ......same.............
W
c, ---•--••------------•------•-•--------------------------------•--•-•----•-------•-•------------•--.....------•-•-•----------•••-----------------•----------......•--•---•-••-------•---•----------------
x •--•-------•--------------------------------•-•-•-•----------------•-----------------------------...--•-••-----•--------------•--------••-•---------•--------------------•--•-----•--------------•------
U Nature of Repairs or Alterations—Answer when applicable...............:...............................................................................
---•------------------------------------------------------•--------------------•--••---.......---•--.....-------------------•---------------------•------------•------------------------•.....-••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L ITI-1: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board o eal�h.
Signed ........... ' ---------- ....-•------.•---
Date
Application Approved BY-------A� "' � � •= 0 £
Date
Application Disapproved for the following reasons---------------•-----•--•------------------------------------....•--•--•---••-•----------•---•-•---.......-•-•--
................•----•---------------...--•--•--•----•-•-----.....--------•...••---------..........------
Date
Permit No......................................................... Issued_---f u -•--------------------•
Date
No.....................•� Fss.3......_...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..•--Town........................oF.......... arnstable
...............................•----•---..............................
ApplirFa#iou for Disposal Works (foustrnrtinn Prrutit
Application is hereby made for an Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot.# 58 Cap'n Crosby Road Centerville, MA _- 02632
.... ._... .._.- •-•• --------- ......... . .....................
Location-Address or Lot No.
---T.x11.st..................................... ...........R&.&...Bax---aaa--_Centerville----••---........_
Owner Address
Kevin Hickey 72 Cr La .Barnstable
........... ....a ...................................... ......Installer _ Address ----_-_---_•
36488
Type of Building Size Lot...-•. ,
......................Sq. feet
Dwelling—No. of Bedrooms............three............
11r ee Expansion Attic (no) Garbage Grinder (no)
Other—T e of Buildingranch No. of persons...........tVQ........ Showers 2 Cafeteria o
a
� Other fixtures ------------------------------------•--------•--...---....----------------------------------------._....-----._.....------------..........__.....----•
W Design Flow............. .......................gallons per person per day. Total daily flow.........2.3aQ.......................gallons.
WSeptic Tank—Liquid capacity__.Q%allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X) , Dosing tank ( )
Percolation Test Results Performed by..................Ronald Gifford Date...Mdy---11, 1979
-
a Test Pit No. 1......2.......minutes per'inch Depth of Test Pit 21.E 1 Depth to ground water........................
----------
fs, Test Pit No. 2......2..._..minutes er inch Depth of Test Pit.._I$.0......._ Depth to ground water........................
a #1 0'-1 .51 - loam- subsoil•.& clay.... 01-1-2 9 5 0 same.....#2
O Description of Soil......----••••.10.5'_-21'._.."_fine.dense---sand......---------------1-2.5.'-_-18..:....razMe.------•-----
x
UW •-•-••--•-••------•-•.....-•-------•--•• ................
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 Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board ofihealth.
7 x
�- �:� 9.20. 9
Signed...
q Date,q
Application Approved BY.....-;--•-�--�_....
,. " Date
-_ .A.........
Application Disapproved for the following reason...... -------------•-•----.......-•---------------•-•••--•--•-•----••......---.....................................
...............•-•--•-•--...----•---------•----------•••--•----•••-•••-•----•-----------•--•-
Date
PermitNo.......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......Town.................,....OF...........Barnstable
r Tutifiratr of To mplia urr
THIS,IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired ( )
.. Kevin H1cke
by -.---•-•-----..... '• .............................----------------------------•--•-•-----•--•---------------•--•--•----.........----•-.....-----•------.
Installer
lot # 58 Capt'n Crosby Road Centerville
at............lot
has been installed in accordance with the provisions of T ' � - of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ��...._�.P?.1.............. dated------Y:!R-6.F._'_.�..�_�.--_._-.....
THE ISSUANCE OF THIS.CERTIFICATE SHAL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......1-f?-^dZe......................................... Inspector..--.6......•.C_..... ...L L ---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town o f Barnstable
1 ............................ .... .
No... .................... FEE.... -d..........
Disposal Wore Taans#rwtion rrutit
Permission is hereby granted H-------------- ---•-----••--..Kevin ickey ... •----
to Construct ( X o Re ( +aij In vidu Se �a a Di )sal S steui
,o #Ft8 Cap n Ms 3 `�B. t'( Virville
atNo...........................................................................•-----............--.--•-•-•--------------•--•••-••-•-••••--•••------•-••----•--•-•-•---•••-••--------..............
Street
as shown on the application for Disposal Works Construction P r"fit No,.�..__._.__-:_____ ated..... .........
Board of Health
DATE-•
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
LQ,CATI N S E W A PERMIT NO.
7tlfl�
VILLAGE
INSTALLER'S NAME i ADDRESS
0 U I L D E R OR '-OWNER ,q
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �_a �_
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