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HomeMy WebLinkAbout0032 CAP'N LIJAH'S ROAD - Health 32 CAP'N LIJAH RD. CENTERVILLE A= 1 C�7/Illl ,, JJ 4ocfci&D 10259 No.C_ H1630R �,. s$'� NASTINai.YN v oa ��c� �p� � ' 333 (� ' �XL�dL) sgr����� �s-r���y 3�e�✓ y r i ONtk 1 - w} a , r ' s , I 1 /1012 1 / 9 C_ Commonwealth of Massachusetts Title 5 Official Inspection Form I e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Cap'n Lijah's ' Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville_ Ma 02632 7/19/19 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. Inspector Information 61 139 8 b on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane VQ Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 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 7/20/19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board ' of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of _� 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate' regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 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: System contains a New 1500 Gallon septic tank as well as a concrete distribution box and two 1,000 Gallon leach pits. Newer pit was installed in 1997 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 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f; 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown 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 �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. CityTTown 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Al Commonwealth of Massachusetts l Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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 Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown 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.cloc•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 _ la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Capin Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 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: Number of current residents: Vacant 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 d 198 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityfrown 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: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 32 Capin Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown 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: New leach pit in 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: System is vented at the roof line 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.): l5insp.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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is Centerville Ma 02632 7/19/19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's are in place. Tank is at normal level t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t,- 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityfrown 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 Level and at normal level 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.): 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 32 Cap'n Lijah's emu, Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityfrown 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: 2 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is Centerville Ma 02632 7/19/19 required for every page. CityfTown 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.): Camera inspection to distribution box showed no sign of failure 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 cam, Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u% 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 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 �n Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 7/20/2019 Assessing As-Built Cards p`(- -J+J TUWN OF BAKNSTABLB G ', 9LOCATION N � 7 S3 VILLAGE ,'«a; -e ASSESSOR'S MAP&LOT�9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO.OF BEDROOMS_ BUILDER OR OWNER V— PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) _ Fat Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fat of leaching facility) Feet Furnished by IS, r4 Sl rGbfit,y �t't- https://townofbamstable.us/Departments/Assessing/Property_VaIues/H Mdispl ay.asp?mappar=192185&seq=1 1/2 c� Commonwealth of Massachusetts ,p Title 5 Official Inspection Form P5. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 1997Date ❑ 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 data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 e Commonwealth of Massachusetts Title Inspection F te5rm o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Cap'n Lijah's Property Address SHIRLEY, GAIL REEVE TR Owner Owner's Name information is required for every Centerville Ma 02632 7/19/19 page. Cityrrown 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. l6 -3 :�> - _i Fee / CO CD � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Disposal 6pstpm construction vermIt Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System DXndividual Components ` vsName, Location Address or Lot No. '(\ �.1 ��S Owner' � Address,and Tel. Assessor'sMap/Parcel s K1 Ct� '�L Installer's Name,Address,and Tel.No.Sa'S `(G(!>Q5_' ' Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size wJ s AC.je,� sq-ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A-)�, gpd Design flow provided ' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. (_C,&< L Description of Soil Nature of Repairs or Alterations(Answer when applicable) � a� c�.A,�.ni�e _��©C�� «i � l 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. c� Si Date Application Approved by Date �✓� Application Disapproved b Date for the following reasons Permit No. &1 b ?l 3 Date Issued ? l L No. . 1 �33 Fee W �/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for ]Disposal i§pstrm Construction permit Application for a Permit to Construct( ) Repair V _Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot Noy Owner's Name,Address,and Tel.No.�`� Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ' 'Pd yak � o��s:�2.d C,Q. �•ra O'� Type of Building: Dwelling No.of Bedrooms Lot Size .35 "je:j sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons -Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) AA 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) ��. ���QG 2: c��pw..e.z—�. koOPi 5.1((cs-/`, 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. Cy Sigped Date Application Approved by Date i Application Disapproved b Date for the following reasons Permit No. & 1 b — 3 33 Date Issued A Z f ?Zv ( L ----------------- ----------------------------------------------------------------------------------------- ----------- �� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ` (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V� Upgraded( ) Abandoned( )byc,gGQ� at Cps, ( j has been constructed in accordance // with the provisions of Title 5 and the for Disposal System Construction Permit No lh—�� dated 9/Z1/ j/6 Installer Rc-QeQ&,,- f— c,d' L,�� Designer #bedrooms Approved design flow 49 gpd The issuance+of this permit shall not be construed as a guarantee that the system will function as designed Date "/ a Z / Inspector ------------------/------------------------------------------- ---------------------- �Kl �3 -- ------------------- � ---------- No.� Fee THE COMMONWEALTH OF MASSACHUSETTS <(�, PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS . Bisposat 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at � � �,%4• , SL\. 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:C nstruction must be completed within three years of the date of this permit Date 2 / oo w Approved b AsBuilt Page 1 of 2 c`! J f ;TOWN Ul'BAKN5.1'AbLh LOCATION_ SEWAGE li_9 7 �� VILLAGE ASSESSOR'S MAP&LOT_ a- L6-5 INSTALLER'S NAME&PHONE NO- -e SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L -ti% y �1 j (size) NO.OF BEDROOMS__ BUILDER OR OWNER 1Moa �' `�"-6+`• "�- PERMTTDATE:_;! 'U COMPLIANCE DATE: ,--[/ - Q 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rr ri, �C i�hT•'y 1" T' http://issgl2/intranet/propdata/prebuilt.aspx?mappar=192185&seq=1 9/22/2016 TOWN OF BARNSTABLJJ LOCATION C Aqz�, L,��; � c SEWAGE# t 3 3 V,,LLAGECC ASSESSOR'S MAP&PARCEL �(a INSTALLER'S NAME&PHONE NO5. SEPTIC TANK CAPACITY ® ` S LEACHING FACILITY:(type)�..�.��-�.. ':�� (size) NO.OF BEDROOMS OWNER ` PERMIT DATE: �� COMPLIANCE DATE: Ilk Separation Distance Between the: C Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)(� Feet FURNISHED BY .� p � LO N`'�- 3,3( j :S / �� ` L r C ',! s se, e t 3 , �5= 3o ® o l COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION y.p Uz' i TITLES OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ?'` SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM r PART A CERTIFICATION *ter Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 ` ' Owner's Name: HENRY CRAWLEY. Owner's Address: 150 DAVID RD FRANKLIN MA.02038 Date of Inspection: 11/15/01 Name of Inspector: (please print) JOHN GRACI Nov O ZOO ' Company Name: SEPTIC INSPECTIONS ° .' BAR EPT BLE Mailing Address: P.O.BOXI-2119 TEATICKET MA.02536 TO\NN OF B HEALTH O Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT aJI�w� I certify that I have personally inspected the sewage disposal system at this address and that the information reported below isap 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: X Passes t 'g , _ Conditionally s s Needs Furthe luation by the Local Approving Authority L : � _ Fails ira ; Inspector's Signature: F Date: 11/15/01 j 4. The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within k Y P 30 days of completing this inspect n. If the system is a shared system or has a design flow of 10,000 gpd or greater,thesf' inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be4 � r sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. , ; Notes and Comments . � THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO x PROLONG THE SYSTEM'S USEFULL LIFE. ` ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This *k _# inspection does not address how the system will.perform in the future under the same or different conditions of use. � '4 Title 5 incnFrtinn Fnrm h/1 S/'600 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMt�, s PART A >>_ CERTIFICATION(continued) ` F Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY, i.„ Date of Inspection: 11/15/01 � Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ; A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310a CMR 15.304 exist.Any failure criteria not evaluated are indicated below. , `b Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: xf _ 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. ` �iE �ica Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. .. , `.. n/a 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' `,� =s; with a complying septic tank as approved by the Board of Health. Y T� *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: n/a ' n/a 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): : _ brokenpipe(s)are re laced �¢v` P _ obstruction is removed ° _ distribution box is leveled or replaced ,k ND explain: n/a :: n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass 4 Y r inspection if with approval of the Board of Health): P ( PP ) _broken pipe(s)are replaced obstruction is removed r {I, ND explain: n/a y ti Page 3 of 11 a �r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :s PART A a CERTIFICATION(continued) n Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 r_ Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 ` 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: s =. _ 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' 4w4�+ n r r 4r 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: 3 _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water t supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. a _ 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 n/a Y FA "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds'indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy ' '- of the analysis must be attached to this form. R . 5�..2 Eby•: 1 3. Other: `*' n/a �4= ,T < . y6 Z Page 4 of 11 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS c . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` '' .k' i• ' x. PART A : : CERTIFICATION(continued) ' Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 j + D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No F - X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool { - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �� , y, - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ` 1 - X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow ' 5 ' - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times3 � pumped nLa. M i - X Any portion of the SAS,cesspool or privy is below high ground water elevation. X An onion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - Y P P P �'Y PP Y rY - X Any portion of a cesspool or privy is within a Zone 1 of a public well. . - X Any portion of a cesspool or privy is within 50 feet of a private water supply well. a - X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with P#` no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory}for coliform bacteria and volatile organic compounds indicates that the well is free m fro r_t from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ,Jr�Ik Y t (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 .fit CMR 15.303,therefore the system failsi The system owner should contact the Board of Health to determine what will be f. , 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. r You must indicate either"yes"or"no"to each of the following: �+ (The following criteria apply to large systems in addition to the criteria above) yes X the system is within 400 feet of a surface drinking water supplyh . - X the system is within 200 feet of a tributary to a surface drinking water supply 3 t Its �rr - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped t Zone II of a public water supply well 'r If you have answered"yes"fo 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 thr®at under Section E or failed under`Section D shall u rade the system in accordance with 310 CMR 15.304.The system owner Pg Y Y should contact the appropriate regional office of the Department. y x::vo� Page 5 of 11 r OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST {' Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 ` r Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 x. Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health ax + X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? _ X Have large volumes of water been introduced to the system recently or as part of this inspection? :yE * X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) r> r X _ Was the facility or dwelling inspected for signs of sewage back up? �_ X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? } , X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the ,aY baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _: X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? =r The size and location of the Soil Absorption System(SAS)on the site has been determined based on: V.... � Yes no X _ Existing information.For example,a`plan at the Board of Health. _54 X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] " f 5� R f; L Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ';TM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 5 '' SYSTEM INFORMATION Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 r FLOW CONDITIONS RESIDENTIAL ' Number of bedrooms(design):3 `(Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 1`5.203 (for example: 110 gpd x#of bedrooms):330 """ , Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO 4' Is laundry on a separate sewage system(yes or no): NO (if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO r:• Water meter readings,if available last 2 ears usage d n/a - , ( Y g (gP ))� Sump pump(yes or no): NO A Last date of occupancy: n/a " =.r COMMERCIALANDUSTRIAL Type of establishment: n/a r . Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow seats/ ersons/s ft etc.): n/a g ( P q Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no):NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a k; f Last date of occupancy/use: n/a OTHER(describe): n/a � 4 t GENERAL INFORMATION' Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/al Et TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system . Single cesspool g P - _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 d ' system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a c '} Approximate age of all components,date installed(if known)and source of information: SYSTEM ORIGINAL WITH NEW'PIT IN 97 R {. • Were sewage odors detected when arriving at the site(yes or no): NO +. r ,5 Page 7 of 11 n OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) _. > Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 BUILDING SEWER(locate on site plan) }« Yr SST F frr } Depth below grade: 18" I Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC ., w Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): y� TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" y `� Material of construction:Xconcrete metal_fiberglass_polyethylene other(explain)n/a a: If tank is metal list age: n/a Is age?confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) M ' Dimensions: 1000G L 8'6"H 5'it7'11W 4' 10"". Sludge depth:2" i Distance from top of sludge to bottom of outlet tee or baffle:32" ka.. Scum thickness:2" V. 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: n/a How were dimensions determined: MEASURED ' ,. Comments(on pumping recommendations, inlet.and outlet tee or baffle condition,structural integrity, liquid levels as related a� to outlet invert,evidence of leakage,etc.): 4r THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFESr GREASE TRAP:_(locate on site plan) A S Depth below grade: n/a Material of construction:_concrete metal_fiberglass polyethylene_other(explain): n/a . Dimensions: n/a a .' Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a �' Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a R �u : Comments(on pumping recommendatons,u inlet and outlet tee or battle condition structural integrity,li uid levels as related k q ,I t to outlet invert,evidence of leakage, n/a 31kn ,, 3. 4f� t { ` Page 8 of 11 �M1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :£ PART C SYSTEM INFORMATION(continued) r .y Property Address: 32 CAPN LIJAH RD CENTERVILLE MA 02632 M190 L185 Owner: HENRYCRAWLEYf. Date of Inspection: 11/15/01 -Arx TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) y :: F Depth below grade: n/a r Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a 'd Dimensions: n/aa R Capacity: n/a gallons a d} r ^ p ty� g Design Flow: n/a gallons/day _> Alarm present(yes or no): N/A y Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): T•' � `A DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) _. Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE _ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into �, F or out of box,etc.): x' BOX IS STRUCTURALLY SOUND. ' r PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a ; ' ' A Yy xr s" V Y f. Y. } R Page 9 of 11 ' a. OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM M xy PART C SYSTEM INFORMATION(continued) Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY ' Date of Inspection: 11/15/01 r.J SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) r. If SAS not located explain why: '' ;4 n/a Type , 000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: nla n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a " aT. rt n/a leaching fields, number: n/a " n/a overflow cesspool, number: n/a ;r n/a innovative/alternative system { t Type/name of technology: n/a Y Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS APPEAR TO BE FUNCTIONING PROPERLY. THE NEW PIT HAS NOT HAD MORE r THAN 2'OF WATER IN IT. BOTTOM 9' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) z Number and configuration: n/a s Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a F ` Depth of scum layer: n/a 7, Dimensions of cesspool: n/a Materials of construction: n/a A Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a .. ,. PRIVY: (locate on site plan) Materials of construction: n/a ' F Dimensions: n/a `�„ ; Depth of solids: n/a ' Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a t lF k l� Page 10 of I 1 r 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM >r PARTCs 't. SYSTEM INFORMATION(continued) Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 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. - ` C f PI J Ql� rr•��r'" - D 4� r `V.1f, AA13 Rif A c Nt Ab k BA a� 1% 31 C C a`G cry �1 : w ` f � i s yy in Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {,; PART C SYSTEM INFORMATION(continued) Property Address: 32 CAPN LIJAH RD CENTERVILLE,MA 02632 M190 L185 Owner: HENRY CRAWLEY Date of Inspection: 11/15/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: } NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) ." NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER IS DETERMINED BY AUGER-NO WATER AT 12' . t•r d+ .lF. 4. r • i.11 if 3 V 8 COMMONWEALTH OF MASSACHUSETTS R EXECUTIVE OFFICE OF ENVIRONMENTAL ' "'fCEI�V -9 CP DEPARTMENT OF ENVIRONMENTAL PRO TIOI e 1 ONE WINTER STREET,BOSTON MA.02108 (617)292-5 ,, 199� �+ O�gA�NSTggC 05 fPT f WILLIAM F.WELD 3 a CORE Governor �/� ' I .� � � Secretary ARGEO PAUL CELLUCCI AVID B. STRUHS Lt. Governor ?r I I r Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,,, PART A 1�a— Cf(`� /V L/�/fr`j/5 CERTIFICATION Property Address: v'`R 1 St A'h15 �o--y t ut 11�ddress of Owner: B VV— �.O` Q��t, Date of Inspection: a111� (If different) 1 y 1A_X4XU14 L Name of Inspector: U9ec$�m Company Name, Address and Telep ne Nu ber: NvL"%,c,: _0Vv�Q6w I Q.()-, kAftn(k� 621.4c a14850 CERTIFICATION STATEMENT S02>-Ck7j_1kAon I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes 'Needs-Further Evaluation By the Local Approving Authority Fails x l Inspector's Signature: Date: a The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: ' Check A, B, C, or D: AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as J approved by the Board of Health. i (revised 11/03/95) i A t� Printed on Rectirled Pacer . r M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,Owner: emga�'`St` Date of lnspection:'�i7," B] SYSTEM CONDITIONALLY PASSES (continued) .1 1 Sewage backup or breakout or high static water level observed in the dist ution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The syst will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due o broken or obstructed pipe(s). The system will pass inspection if(with:approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEAL Conditions exist which require further evaluation by the Bo d of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D RMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a su ace water Cesspool or privy is within 50 feet of a b rdering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANN R THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank an soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank d soil absorption system and is within a Zone 1 of a public water supply well. _ The system has a septic tan and soil absorption system and is within 50 feet of a private water supply well. The system has a septic to and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a wel water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm' 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ah t 5 va Owner: QpMo-\.+j0 Date of Inspection: •�`,`�-1 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine.what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 CntpT 15 514Y1,S W0.A Owner: Qpyn�c�o�c7 Date of Inspection: Q Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. XNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. -&The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. / The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. XThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. IThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Ca,,j7- \Ar\r\�5 W� Owner: Q0Vy1,ok c1 N p Date-of Inspection: aA�``k:l FLOW CONDITIONS RESIDENTIAL: Design flow: 3V_gallons Number of bedrooms: O;5 Number of current residents:�- Garbage grinder(yes or no):Ln Laundry connected to system (yes or no Seasonal use (yes or no):_LId Water meter readings, if available: fj Last date of occupancy: U COMMERCIAL/I NDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sourcR�of information: " A Systeln pumped as part of inspe ion: (yes or no) No If yes, volume pumped: ¢allons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: \SH`�C Sewage odors detected when arriving at the site: (yes or no)_L� (revised 11/03/95) 5 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property ddress: Z (24P� Owner: qq Date of Inspection: 1 l SEPTIC TANK:* (locate on site plan) d Depth below grade:_J_Z Material of construction: concrete _metal _FRP —other(explain) Dimensions: ICQ2)QW1 Sludge depth: �t Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: Distance from top of scum to top of outlet tee or baffler it Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struct al integrity, evidence of leakage, etc.) GREASE TRAPAJ-0 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /�� SYSTEM INFORMATION (continued) Property Address: 3Z QP "T7`vI PV (f S Owner: Date of Inspection: h TIGHT OR HOLDING TANK:_VC9 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: .(,s (locate on site plan) Depth of liquid level above outlet invert:, Comments: (note if level and distribution is equal, evidence of solids car over, evidence of leakage into or out of box, et ) C �V PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z.(?A f �C Owner: 1 10 Date of Inspection: ` G SOIL ABSORPTION SYSTEM]AS) IvIt(locate on site plan, if possible; excon not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Com ents: (note condition of soil signs of hydraulic failure, level of onding, Condit' n of vegetation,etc.) e iu - CESSPOOLS: (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 (cesspool must be pumped as part of inspection) 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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /t SYSTEM INFORMATION (continued) Property ddress: 3Z CAPI s I n hIS Owner: XDMkVj0 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �PA 8 A (2) z y 4Z- M- � `l 6q-a-1 DEPTH TO GROUNDWATER Depth to groundwater: � Meet method of determination or approximation: suevouf (revised 11/03/95) 9