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HomeMy WebLinkAbout0127 CLIFTON LANE - Health 127 CLIFTON LANE _ CENTERVILLE A =�247 122 � { No. 42101/3 ORA G (3\n C ESSELTE 10% (a O ® O 0 - -- - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r ti 127 Clifton Ln. _ Property Address Susan Sirica — Owner Owner's Name / information is Centerville ✓ Ma. 02632 8-26-20 required for every - - — — - page. City/Town State Zip Code Date of Inspection , - r�z Inspection results must be submitted on this form. Inspection forms may not be.altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, use only the tab _Michael Sears key to move your Name of Inspector T cursor-do not Jim The Inspector Man use the return key. Company Name P.O.Box 784 Company Address West Yarmouth _ Ma._ 02673 City/Town State Zip Code 508-364-4398 _ S114430 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 a 2. ❑ Conditionally Passes ,�,�� .• ssq�y., MICHAEL (P 3. ❑ Needs Further Evaluation by the Local Approving Authority o: SEARS No.SI14430 :In 4. ❑ Fails '4 !•• • RTIF� O 5 IIIN i`� � 8-26-20 Inspector's ' nature 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.7/2612018 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 c ! 127 Clifton Ln. - �� Property Address Susan Sirica _ Owner Owner's Name information is Centerville page. Ma. 02632 8-26-20 required for every Ci ty/T own 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: 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 r <�IIN� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Ln. u� Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every - - • — — — - page. Citylrown 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments eta!% 127 Clifton Ln. Property Address Susan Sirica _ -- Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every - - -- --- page. Cityrrown 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) is functioning in a manner that protects the public health, determines that the system g 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 l, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < !% 127 Clifton Ln. Property Address Susan Sirica _ Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every — - -- — — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 C.4. 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form .ilb Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Clifton Ln. Property Address Susan Sirica Owner Owner's Name information is required for every Centerville Ma. 02632 8-26-20 -- — — - — -- 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 ® El 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 c Commonwealth of Massachusetts ,r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 127 Clifton Ln. Property Address Susan Sirica _ - Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every —— - page. Cityrrown 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: 1 �I Number of current residents: 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 2018- 53000 gal g ( y g (gp )�� 2019-76000 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: present Date tsinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 cat'\ Commonwealth of Massachusetts Title 5 Official Inspection Form f- ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Clifton Ln. Property Address Susan Sirica_ Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every - 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(gpa) 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 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� � ,_f 127 Clifton Ln. - `J Property Address Susan Sirica_ - Owner Owner's Name information is required for every Centerville Ma. 02632 8-26-20 — --- - ,. -" - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 11-7-11 #2011-389 _ Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 4311 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain): — -- Distance from private water supply well or suction line: feel Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 118 f cam, Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 127 Clifton Ln. Property Address Susan Sirica --- Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every -- -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): _ 33„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 gal -- --------------- If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 al Sludge depth: - -- Distance from top of sludge 29"to bottom of outlet tee or baffle - 0 Scum thickness — 8" Distance from top of scum to top of outlet tee or baffle -- - Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank within and out tees, outlet cover ar 2" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 18 c , Commonwealth of Massachusetts .- Title 5 Official Inspection Form = �l, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �!'f 127 Clifton Ln. Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8-26-20 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form l� �1 _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 127 Clifton Ln. — ``�� Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every —— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 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 16x16 with 3 outlet pipes at 4' below grade under paved driveway t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r c , Commonwealth of Massachusetts Title 5 Official Inspection Form r� . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Clifton Ln. _ _ — �� Property Address Susan Sirica — Owner Owner's Name information is required for every Centerville Ma. 02632 8-26-20 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: ❑ leaching chambers number: ❑ leaching galleries number: -- ❑ leaching trenches number, length: ® leaching fields number, dimensions: 3 rows of 6 ARC ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology: -- l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �= 1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments hP 127 Clifton Ln. _— �� Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every m-- -- -� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 36 biodiffusers, 6 in 3 rows camered field dlean and dry with 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 e.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C 127 Clifton Ln. Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every -- --- - - -- page. Citylrown 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 r 'c1 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessme is r Vl 127 Clifton Ln. _ _..---- —....__ —_-- Property Address Susan Sirica Owner Owner's Name information is Centerville Ma. 02632 8- 6-20 required for every ---- - --- page. City/Town State Zip Code Mc to 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 ��..6 3- y-` 3 30' _ n C3- )0 6 q A I �' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewag Disposal System•Page 16 of 18 ' Commonwealth of Massachusetts • - , Title 5 Official Inspection Form ,;� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 127 Clifton Ln. u Property Address Susan Sirica _— Owner Owner's Name information is Centerville Ma. 02632 8-26-20 required for every ---- - - -- -- page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 144" _ 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: 11-3-11 _. 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: No ground water at 144 per 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 <f1\1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vic !% 127 Clifton Ln. Property Address Susan Sirica -.- Owner Owner's Name information is re Centerville Ma. 02632 8-26-20 wired for every — - q page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included J . (ryraclz c4 SAS 5J is /V 0 e t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 0 PUBLIC HEALTH DIVISION —TOWN OF BARN STABLE,'MASSACHUSETTS Yes plitatiou for disposal 6pstrm Construction j3ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.`R 7 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel p71/7— /o?p2, (� �'Q� ��l lg4lly Installeerrr''s Name,Address,and Tel.N . Q^11)4L. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)`��� gpd Design flow provided gpd Plan Date .! 4/ Z` Number of sheets / Revision Date Title `` Size of Septic Tank fj -$l/,,,.t) Type of S.A.S� il—�xN S [ �i Lk,1_Z_0 Description of Soil _( U-1i p T Nature of Repairs or Alterations(Answer when applicable)��"-1 A_5 , Date last inspected: Agreement: The undersigned agrees to ensure the contronmental ction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E Cod d not to place the system in operation until a Certificate of Compliance has been issued b this Bo a th. i ed o �' ate Application Approved by ate Application Disapproved by Date for the following reasons Permit No. Date Issued ----------------------------------- - --------------------------------------------------------------------------- � f No. Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l' Yes l/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTAB�LE;"MASSACHUSETTS Rpplication fg- UspoBal 6pstem CoBstructio'n Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./�?7 Clj jc� ( ��� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel b7V7...- /a Installer's Name,Address,and Tel.N0(9 ,f4D,/✓(-)4L Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms - S Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers.( ) Cafeteria( ) Other Fixtures Design Flow(min.required)`?�(] gpd Design flow provided ,/ gpd Plan Date �/7 ���/ Number of sheets / Revision Date Title ' 4 Size of Septic Tank Type of S.A. -79 t�c Description of Soil Nature of Repajrs or Alterations(Answer when applicable)—�.,��o%� U Date last inspected: Agreement: The undersigned agrees to ensure the con uction and maintenance of the afore described on-site sewage disposal system in k= y - accordance with the provisions of Title 5 of the E ronmental Code d not to place the system in operation until a Certificate of Compliance has been issued by this Bo e th. i ed I -ate l/ / Application Approved by Date r Application Disapproved by U Date for the following reasons Permit No Date Issued i ----------- ----------------------- - --------------------------- ---- --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site wage Disposal system Constructed( ) Repaired Upgraded(� bdoned( )by >./y at !16,,—&Aj _ has been constructed igacc :d nce with the pro ' ion of Title 5 M7:61 for Disposal System Construction Permit N . ted Installer �1oej9, UA( d;6,-t) Designer'�,��. A X,4,4 #bedrooms Approved design flow �j �� gpd .� The issuance of this permit shall not be construed as a guarantee that the syst will funct'n de 'gned. Date Inspe•tor ----- --- ------------------------------------------------------------------------------------ ---- ---.----------------No Fee_ _/ THE COMMONWEALTH OF MASSACHUSETTS , PUBLI HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pstem (-Construction Permit Permission is hereby granted to Construct Repair( Upgrade ) Abandon 7 System located at 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:Constructio ust b c leted within three years of the date of this permit. Date Approved by J f Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division MAM oa Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 ° Office: 508- 62- 44 11 Fax: 508-790-6304 Date: Sewage Permit; Assessor's Map/Parcea L/7�1 p Installer&Designer Certification Form Desi gner: �� �/`�1� " I Installer: � » Address: Address: ��_ VJ64✓� On /l ns was issued a permit to install a (d ) (installer)septic system at� 127 �I�: L.)- 1 based on a design drawn by$ (address) dated (designer) k I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation.of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &LocaLRl ''-pions. Plan revision or certified as-built by designer to follow. Stripout(if rP- - -acted and the soils we e found sa actory. H OF Mq s DAVID �y o B. �.� m1 nsta r MASOy ignature) 9 No.1066 0 esig ier s-Signature) q ' PLEASE RETURN TO BARNSTABLE PUBL.- fE OF COMPLIANCE WILL NOT BE ISSUED UN i t-L jsv i n i niN ii'URM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc 41 � -z TOWN OF BARNSTABLE 'LOCATION X" ��/_/���✓(/ .CN• SEWAGE # VILLAGE SSESSOR'S MAP & LO� ?� INSTALLER'S NAME&PHONE N SEPTIC TANK CAPACITY .Q 1 LEACHING FACILITY: (type) .S 4F (size) �o X . NO.OF BEDROOMS,1 �elv BUILDER OR OWNER Lai i/ G/1 i' t • C PERMITDATE: jYtween % COMPLIANCE DATE: Separation Distance B the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) - Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 110 . • of� Town of Barnstable P# ' Department of Regulatory Services F Public Health Division j / 1 MASS. Date l I .200 Main Street,Hyannis MA 02601 Date Scheduled / Time( Fee Pd, Soil Suitability Assessment for Sew Disposal Performed By: Witnessed By: LOCATION&GENERAL INFORMATION Location Address�°��f /I� .1�N Owner's Name 4 v/&,41 Address Assessor's Map/Parcel:517 / Engineer's Nam NEW CONSTRUCTION REPAIR Telephone# Tf Land Use: Slopes(%)' Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) W� i C) s - 3 Parent material(geologic) OV t w I Depth to Bedrock I Oo Depth to Groundwater. Standing Water in Hole:__ t_ Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: In. Depth to weeping from side of obs.hole: In, Groundwater Adjustment Ct. Index Well# Reading Date: Index Well level Adj,&ctor Adj.Groundwater Level PERCOLATION TEST Batt: Thne Observation I Hole# Time at 9" Depth of Pere _' Time At G" Start Pre-soak Time @ 2 Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Consel}vation Division at least one(1)week prior to beginning. Q:XSEPTIC\PERCFORM.DOC . r { DEEROBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. h.n < l Consistency.%'Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Xj MAC i945 ✓ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co i to Oravell DEEP OBSERVATION HOLE LOG Hole# Depth firm Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary Nov, Yes Within 100 year flood boundary No.r Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious matarial? /V'q Certification I certify that on CI (date)I have passed the soil evaluator examination approved by the Department of Envii-Amental Protection and that the above analysis was performed by me consistent with . the required training,exper' an pedence described in 310 CMR 15.017. Signatur Date �1 Z0 r Q:\.S.EP'rl0PERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 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.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, I use only the tab 1. Inspector: key to move your VV V cursor do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental inspections Company Name P.O.Box 896 Company Address East Dennis MA 02641. Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address anti that thee-' information reported below is true,accurate and complete as of the time of the inspecbi n.The inspectio�t was performed based on my training and experience in the proper function and mairitetance of Q sited sewage disposal systems. I am,a DEP approved system inspector pursuant to Section 15.340 of -, Title 5(310 CMR 15.000).The system: N ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i� 08/19/11 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use.. t5ins-11/10 Title 5Offcial Inspection Form:Subsurface ge Disposal System-Page 1 of 17 , Commonwealth of Massachusetts Title 5 Official inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y,N, ND)for the following statements.If"not determined,"please explain. The septic tank is metal and over20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonweaiffi of Massachuseft Ville 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is regfared for every Centerville MA 02632 08/18/11 page. City/Yo-n state Zip Code Date of inspection B. Certification (cont.) B) System Conditionally Passes(coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1 Hb)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ® Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 . TGie 5 Official Inspection Form:swmftce sewese Dtspesat system-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. CitylTown state Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable tor 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 ❑ 0 Liquid depth in cesspool is less than 6°below invert or available volume is less than l day flow t5ins•11/10 Tile 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 4 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. City/Town state Zip Code Date of Inspection. B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed:pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.l 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"non 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 11 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 answerers "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 31.0 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage"Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11' page. Cityrrown 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. ® ❑ Detenrnined in the field (f any of the failure criteria related to Part C is at issue approximation of:distance is unacceptable)[310 CMR 15.302(5)]: D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example:.110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts v. Y Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. City[Town state Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? [f yes separate inspection required] ® Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 06/11 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: T Us 5 FC,"m:S;:b5';h aCa ^tpc.;al SyMm^Pegg 7 Qs 17 I Commonwealth of Massachusetts Title 5 Official Inspection 'Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity,pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool' ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Same information is required for every Centerville MA 02632 08/18/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 0421/99 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ®' No Building Sewer(locate on site plan): Depth below grade: 3.7 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: 3.1 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years. Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 3" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 , page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness Y Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural'integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins=?V10 T Ie 5 Official Inspec5on Form:Subsurtace Seviage.Disposal Sift on.-Page 10 C 17 Commonwealth of(Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. Cityaown State Zip Code Date of Inspection. D. System. Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level-- Alarm in working order: ❑, Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑! Yes ❑ No t5ins•11110 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville NIA 02632 08/18/11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution.Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out.of box,etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of W l I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching,galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemativesystem Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): This system has 2 500 gallon drywells in a12.5')Q5'field of stone.There was no liquid present with no sign of ponding or failure. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton Lane Property Address Sam TrayWck Owner Owns Name information is required for every Centerville MA 02632 08/18/11 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetis Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 127 Clifton lane PM"Address Sam Traywic k owner Owner's Marne ifftm u`ticM is Centerville MA 02632 08/18/11 required for every page- City/Town State zipCode Date of Inspection D. System Ilnfof nation (corn.) 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 Q drawing attached separately Qeox � c6 1 �1 f5ms-11H0 Tft 5 otfiei YapecGon Fomr S 5 Dim t5 d t7 Commonwealth of Massachusetts Title 5 Official Inspection Form s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is Centerville MA 02632 08/18/11 required for every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-.(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 127 Clifton Lane Property Address Sam Traywick Owner Owner's Name information is required for every Centerville MA 02632 08/18/11 page. City?own State Zip Code Date,of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 % No. ' ZU / , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Migpotai *pgtem Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) IV/complete System O Individual Components Location Address or Lot No. Owner's N e,Add s an Tel.No. 177Cj �o�r ,�, � �r7 �a/�®�j Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 71 Type of Building: Dwelling No.of Bedrooms ' Lot Size sq.ft. Garbage Grinder(�0 Other Type of Building PS/ el No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3ro gallons per day. Calculated daily flow J� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank s9 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y this B pardof Health.Signed Date T Application Approved by Date —Z%- 0212 Application Disapproved for t e following reasons Permit No. �� 'Z6q Date Issued 7"Z/ `2 _Z / /' �. � -N�� ., Z v L/ :a}� &.# .._ Fee THE NWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 11pplication for Xkgoml *p.5tem Construction Vermit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) IV Complete System ❑Individual Components Location Address or Lot No. Owner's N e,Address an Tel.No. rz�c%ref©� /,� la ��� �Q`o/�;,�09 Assessor's Map/Parcel ✓ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 77 - YY' Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinderd Other Type of Building i°5% .,°/ll e No. of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow 3 3� gallons per day. Calculated daily flow3o gallons. " Plan Date Number of sheets Revision Date Title / Size of Septic Tank /$FOD 9'O/ ' Type of S.A.S-�' Des_cription of Soil 7 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y this sBBpar of Health__ Signed Y/ "t Date Application Approved by /- Application Disapproved for the following reasons ° Permit No. _2 a� Date Issued 7 -Z --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 2! 7--/7 Z BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERjPFf,1 that the On-site Sewage Disposal System Constructed( )Repaired(-_11)Upgraded( ) Abandoned( )by �/'I / at 2 7 C/i fO/1 C e f/// tp has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer n G The issuance of this e ' t s�}all not be construed as a g uarantee that the s st till function as Ai ned� Date p 1 Inspector ,A 11 -- j—c�--------------------------7----------- C No. 1 / 0 V G 6( � 7-7` � Fee S�, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Xkgogar *pztem Construction Vermit Permission is hereby granted to Construct( ) epair(lam)Upgrade( )Abandon( ) System located at l Z 7 C/OzT_* !/t. CG yl1Q!//�/�E' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must becompleted within three years of the date of th' e t. ` n Date: �— Z / - /l Approved by -�l�/ a: 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS). I, T it �DG� /, hereby certify that the application for disposal works construction permit signed by me dated c�/ZQ�� , concerning the L r property located at Z G/l�' �� !/�� 6,e&*1(1/11e- meets all of the following criteria: JV The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /There are no wetlands within 100 feet of the proposed septic system u/ There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed ,/ There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor m thod when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 6a i f B) Groundwater Table Elevation 1 Z' F max adjusted g.w. Z _ `5 `3 DIFFERENCE SIGNED : DATE: [Sketch proposed plan of system on back]. ira. TOWN OF BARNSTABLE c� LOCATION lZ G°' � /4' SEWAGE # VILLAGE P ���/�` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �hs7` 7�� SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) 5',' Z%(Le*S l/weAy-j (size) /,Z,1'A.2.r NO.OF BEDROOMS BUILDER OR OWNER iWf S PERMITDATE: I, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y" Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist t9 Feet within 300 feet of leaching facility) Furnished by >Ji ' I ;U I � 1 �c e � I TOWN OF BARNSTABLE LOCATION l2-` ��? <�' SEWAGE # VILLAGE � �l✓//G ASSESSOR'S MAP & LOT `l0'?— INSTALLER'S NAME&PHONE NO. A/'ZeZ;� SEPTIC TANK CAPACITY ffIkO 641 LEACHING FACILITY: (type) 0/1 b*11-*4 e/" - (size) 1.2, NO.OF BEDROOMS 3 BUILDER OR OWNER Per 1O PERMITDATE: VIA/ COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility — Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �'/✓ Feet Edge of Wetland and Leaching Facility(If any wetlands exist 3 J I within 300 feet of leaching facility) Feet Furnished by '' x 00 Y , 1 0 ASSESSORS MAP : �z"7 7 _ TEST H a _E LOGS NOTES:t� PARCEL: # 120 r FLOOD ZONE: /(./D� 7L/�,,�(;gL,� SOIL EVALUATO t ; NIP od kCl'�' 1) The installation shall comply with Title V and "Town of �l3 9oard of % WITNESS : 0k'. Ilealth Regulations. REFERENCE: �,>44�,/ Or" �, ,0 DATE : �./(7V"� O// 2) The installer shall verify the location of utilities, sewer inverts and septic ��/ 6U/LV46 /Z>4 �,/ PERCOLATION R Y, : G Z n'1��/ / components prior to installation and setting base elevations.�/ zo� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first --� two feet out of the d-box to the leaching shall be level. TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other A /-°'��y r L1 co" S 3 purpose other than the proposed system installation. _ A �J r `� _ _ 5) All septic components must meet Title V specifications. I Ga /� .l 6) Parking shall not be constructed over II10 septic components. v ✓ �� 1� 7) The property is bounded by property corners and property lines. LOCATION MAP - �� -- 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt J .� of payment for the plan and installation based on the plan shall be deemed CC p�tT� approval of the design flow by the owner. I 9) The existing leaching or cesspools shall be and filled with material pumped per Title V abandonment procedures. Those within the proposed SAS shall rr t be removed along with contaminated soil and replaced with clean sand per I� �o w �3, • ' - �• � ---- Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the 00 ` • water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if � applicable. The proposed SAS is being installed below the water service\ 20'56 SEPTIC SYSTEM DES I G N line. The line is to be sleeved as aforementioned and maintained in place. ' N 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. - - • . '. EEDROOMS AT I GAL/DAY/BEDROOM -?� GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. SEPT:C TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. 2 Z GAL/DAY x 2 DAYS - b100 GAL USE 15�0 GALLON SEPT I C TANK r- )A/ - - WOF V OF Mqs\ SOIL ABSORPTION SYSTEM DAVID s9�y _ I o vy: 3 Rov�S HZ0 co ►4�. Co ►�ISON 066 Flo :�TbW Vj/ 1140, CutiL�> 0 _--c I _ - t s ow x (0 LOT 5B I =� — �T��- 1 �--- }— #127 . .. SEPTIC SYSTEM SECTION (41 LOT 5,7 / Q E-J-)A h,� pw i 5P T�oud �b Ly L�A."7 NF \\72 U p o p e 0 0 0 5rai GAL D I p 0 SEPTIC TAtJ � ucf►t,� w GLirN�l rcrt N\ , . s so. � t Cf OQf OF p 4�2S q�EMeNT F �S. 00 f�23 S\ �\ \ SITE AND SEWAGE PLAN LOCATION : -0 1 Z GLl1"1 N �--Alg6 TD � o Uw rzDPd�'tvO PREPARED F0 P I "� '� __ R C,►�L�I W V�1. Covie.�;72Uc.�Tid4 M GC7T'L)T j l� o • ►- = SCALE : DAV I D B . MASON 1R5 DATE : II ZDI DBC ENVIRONMENTAL DESIGNS = EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2 177 r