HomeMy WebLinkAbout0152 CLIFTON LANE - Health 152 Clifton Lane
247-015 Centerville
UPC 12543
No -CO
IIASTINGS. LIN
:..
Commonwealth of Massachusetts
ritle 5 Official Inspection Form
? Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a
^N 152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. CityrFown
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out ✓J
forms on the
computer,use 1. Inspector:
only the tab key
to move your MICHAEL DEDECKO
cursor-do not Name of Inspector r
use the return
key. COMPASS REALTY DEV CORP I
Company Name -•?
rsn P.O. BOX 2384
Company Address Y-1
MASHPEE MA S-:� 02649--
Cityrrown State i Zip Code'
11
508-221-5003 ' �—
Telephone Number License Number C>) r—
r`i
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs`Further Evaluati by the Local Approving Authority
9/10/07
Inspe tor's Ignature 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
64 camp opechee•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. CityrFown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup o�dreak ue to a broout rken highs ttled ostatic atuneven distribution box. System will due to broken or obstructed pipe(s)
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
64 camp opechee•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.•'' 152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is required for CENTERVILLE MA 02632 9/10/07
every page. City[Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
'i
❑ 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.
64 camp opechee-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or.cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
El ® 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.
64 camp opechee•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is required for CENTERVILLE MA 02632 9110/07
-
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria'indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
0 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If j ou have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
64 camp opechee•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. City/Town
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?
® El available
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)]
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
64 camp opechee-08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. Cityrrown
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
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
n/a
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
N/A
Last date of occupancy: 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:
Last date of occupancy/use: Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
64 camp opechee•08106
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
General Information
Pumping Records:
n/a
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
El maintenance
technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
93
Were sewage odors detected when arriving at the site? R ❑ Yes ® No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
64 camp opechee-08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints tight yes vented no sign of leakage
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------
1000 gallons
Dimensions:
3"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
31"
1"
Scum thickness
11" .—
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
measured
How were dimensions determined?
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
64 camp opechee•08/06
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is required for CENTERVILLE MA 02632 9/10/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
no need to pump , tee's intact structurally sound, liquid level equal with outlet invert, no leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
64 camp opechee•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. Cityrrown
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
64 camp opechee•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
soil gravel, no sign of hydraulic failure, ponding 2' no damp soil vegetation normal.
64 camp opechee-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
, Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is required for CENTERVILLE MA 02632 9/10/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions --
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
64 camp opechee•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
II
v
0
64 camp opechee-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
152 CLIFTON LANE
Property Address
KERWIN, SUSAN M &STEPHEN A
Owner Owner's Name
information is CENTERVILLE MA 02632 9/10/07
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
38.18'
Estimated depth to 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: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
town of barnstable gis
You must describe how you established the high ground water elevation:
town of barnstable gis topo shows ground elevation at 38.18'
64 camp opechee•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Town of Barnstable
OF IME Tp�
Regulatory Services
rrsrnar� Thomas F. Geiler, Director
9� 6 9 ••� Public Health Division
ArEp�.�A
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
I
COMMONWEALTH OF MASSACHUSET M ASSESSORS MAP NO, a�"� -7
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS PARCEL NO' 0 s
F-9DEPARTBI.NT OF ENVIROPT=NTAL PROTECTION
RECEIVED
David B.Mason,RS,Certified Title V Inspector,508-833-2177
JUL 0 2 2004
TOWN O FBH NSTABL'E
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 152 Clifton Lane,Centerville,MA
Owner's Name:Stephen Kerwin
Owner's Address:25 Independence road,Bedford,MA 01730
Date of Inspection:June 24,2004
Name of Inspector:(please print)David B.Mason
Company Name:-
N.A.-Mailing Address: 4 Glacier Path
East Sandwich,MA 02537
Telephone Number.508-833-2177
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000h The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
WXInspector's Signature. Date: 4 7A
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.
Notes and Comments: System as inspected appears to have operated based on occupancy level. Increase in
occupancy may cause hydraulic failure.The information as identified represents only the condition of the system on
June 24,2004 at 2:30 PM.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stephen Kerwin
Date of Inspection:Jerre 24,2004
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 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced (THIS IS REQUIRED TO BE
COMPLETED)
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stephen Kerwin
Date of Inspection:June 24,2004
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(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria 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.
3. Other:
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
Page 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner: Stephen Kerwin
Date of Inspection:June 24,2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
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
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
NA Liquid depth in cesspool is less than 6"Below invert or available volume is less than '/a day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_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 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 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.J
NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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.
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 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 H of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 152 Clifton Lane,Centerville,MA
Owner: Stephen Kerwin
Date of Inspection:June 24,2004
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
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?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_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?(INCLUDING THE SAS)
X_ _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
mainten_ ance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information.For example,a plan at the Board of Health.
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))
v
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 152 Clifton Lane,Centerville,MA
Owner: Stephen Kerwin
Date of Inspection:June 24,2004
FLOW CONDITIONS
RESIDENTIAL
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): 330gpd
Number of current residents:
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): 2004;18,000 gal. 2002;11,000 gal.
Sump pump(yes or no):No
Last date of occupancy: (current)
COMMERCIAIdINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): god
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):i
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Property owner
Was system pumped as part of the inspection(yes or no):Yes,after inspection for pumping maintenance purposes
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:Suggested pumping maintenance.
TYPE OF SYSTEM
_ Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP�.approval
X—Other(describe):Septic Tank and Leaching pit
Approximate age of all components,date installed(if known)and source of information:Tank is about 15 years old.
Leaching is about 6 years old.
Were sewage odors detected when arriving at the site(yes or no):NO
f
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stephen Kerwin
Date of Inspection:June 24,2004
BUILDING SEWER(locate on site plan)
Depth below grade:Approximate; 16 Inches
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK:N.A.(locate on site plan)
Depth below grade:4"
Material of construction:X_concrete metal_fiberglass_polyethylene_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Typical 1000 Gallon Tank
Sludge depth: 5 inches
Distance from top of sludge to bottom of outlet tee or baffle:24"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle: 16"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined:actual measurements
Comments(on pumping recommendations,inlet and outlet tee or bate condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)Requires maintenance pumping. Outlet tee is precast and in
good condition. Appears to be slight plumbing leak due to continual flow.
GREASE TRAP: N.A.
Depth below grade:—
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM--NOT FOR VOT IJNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stphen Kerwin
Date of Inspection:June 24,2004
TIGHT or HOLDING TANK;—N.A.—(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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_NO_ _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even with outlet pipes. One-outlet pipe had a flow leveler.
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): No distribution box could be identified.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Page 9 of 11
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stephen Kerwin
Date of Inspection:June 24,2004
SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required)
If SAS not located explain why:
XType
eaching pits,number(1)6'wide x 4' deep w/approx.2' of stone around
_leaching chambers,number:
_leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition'of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc)indication of staining 2'off bottom of pit,4"of effluent in bottom of pit,no ponding or damp soil,no
vegetation over pit.
CESSPOOLS: NA (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc):
PRIVY: N.A._(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.):
Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 152 Clifton Lane,Ma
Owner: Stephen Kerwin
Date of Inspection:June 24,2004
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.
W
/9
OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS
Page 11 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 152 Clifton Lane,Centerville,MA
Owner:Stephen Kerwin
Date of Inspection:June 24,2004
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X Obtained from system design plans on record-If checked,date of design plan reviewed:
X_Observed site(abutting property/observation hole within I50 feet of SAS)
_X Checked with local Board of Health-explain:Recent Test Holes, Existing_engineer records with BOH
_X__Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board ofHealth. Additionally,existing site and abutting
site topography does not indicate ground water to be within 5 feet of bottom of leaching facility. Depth of ground
water would exceed 20 feet below grade.
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NO.OF BEDROOMS �-2 11
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PERMITDATE: 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
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PERMTTDATE: 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
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Edge of Wetland and Leaching Facility(If any wetlands exist
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Separation Distance Between the:
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Private Water Supply Well and Leaching Facility (If any wells exist
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Edge of Wetland and Leaching Facility(If any wetlands exist
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