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Home My WebLink About0041 CONNERS ROAD - Health 41 CONNORS ROAD, CENTERVILLE A=251-027 jl I - UPC 125,13 HASTINGS, fdN e Commonwealth of IMassachuseft Title 5 Off icial l e ti n For Subsurface Sewage Disposal System Rs ri Not for Voluntary Asses„rnents Co vl✓1�e,-.s Property Address s_,....._.._..� Z_zow er information is ON ner's Name required for every �Vr�+'C�' v I Ile— page- City/Town State Zip Code Date of/Inspe6tion O1 . 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. tmportfor A. General Information ' filling out ling outut form on the computer, use only the tab 1. Inspector key to move your cursor-do not o/f e,!l use the return Name of Inspects ,__C Vk1l CH Company Nam 6_/�0 O x t� o� _ Company Address t;1ty/Town O ago _ �0 State r)d Zip Code Telephone l4imber ` License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5"OR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Further Evaluation by the Local Approving Authority n�lq //_1)", 9 / / (o InspecTs 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_god 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 ttescribes 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. tSrs•3f13 TitleSofficiallrspeefienF_SubsrafaWSewageDispOsal$)mm•P ge 1of17 Ord v� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage;Disposal System Form -Not for Voluntary Assessments �l CO A 0.er f R �i Property Address / L 10,0 2r�rej ON ner Ory nees Name information is required for every _ 2v► / page. City rrown State Zip Code Date ofIns tion B. Certification(cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) :7�lhave m s: not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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 ex0ain. 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): z iyrc;•3h 3 Title 5 Official Inspection Form Subsurface SeYoge Disposal System•Page 2 of 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Secw.aage Disposal System Form -Not for Voluntary Assessments Property Address 6 L Pro se -1r.Qf Oar ne O+v ner's Name hforrequired at fo is CQvt tit 2 0�6 �,Z kphl' requ"ved for every page. Ctyfrown State Zip Code Date of Kspecti6n B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed Pe i (s)or due to a broken settled or uneven distribution box. System will pipe(s) Pass ins if with approval of Board of Health): inspection ( PP ❑ 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): re than 4 times a year due to broken or obstructed pipe(s). The ❑ The system required pumping more Y Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 official Inspection Form SubsWace sevJ9e DisPosal SyMln•Page 30f 17 19ns•3M 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ug [ l l co 0 l4tvf iqj Property Address n ON ner (� pub 4/4l,e Owner's Name /'requmatifor a 1. __ /�j required for suety �`" ✓!�� page. Ckffown State Zip Code Date of Insp coon Be Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic 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 coliforrn 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 ❑ L—�/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tatic 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 tSns•3H3 TitleSOffiaallnspectonForm sutsufacesevageDisposal System-Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ///1 Co V1 Owner 1� 6L rO e/41�J' aifome is Owner's Name / O required for every Cell �/✓ Vd-CC ✓! G page. 5i-frown State Zip Code Date pf Ins tbn B. Certification (cons.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ L� 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 ftributary to a surface water supply. ❑ Lam! Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ny 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- 10,000g pd. ❑ 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 ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered `yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ms•3113 Title 5 Official iris pectlm F ams Subwface Sevgle Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address l I Co`400 ee s 12 lyL 10 w «s Ojv ner Orr ner's Name information is / required for every Ce�^4,e;.,of page. Cityrrown State _ Zip Code Date 6f Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o ❑ 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? Kthe system received normal flows in the previous two week period? large volumes of water been introduced to the system recently or as part of nspection? e as built plans of the system obtained and examined?(If they were not available note as WA) 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 nspected 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 n 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 Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions Number of bedrooms Number of bedrooms (actual). - (design): 3 30 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 9� t5re•3/13 Tile 5 Official IrepwbonFcmSub rfaceSewageDisposalsystem•Page6of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 1// co"NQrrf A?j Property Address Ow ner ON ner's Name II__ •• // �(enfomtiat�n isC2 w-+�✓l/l l�l G /Fj 0, t squired for every page. Cityrrown State Zip Code bate of spection D. System Information Description: / &0 �`/o� -,Ce 4c` CZ Number of current residents: Does residence have a garbage grinder? 2r Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes ��No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o C !iL✓/t s„ Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: tSrre,3M 3 Title 5Official Inspection Form Subsurface Sewage Disposal S)stem-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / / COwo•Q✓S /e Property Address ! Ow ner Ow nees Name information is required for every l�2 v►-F�✓yG` /" page. Cityfrown State Zip Code Date of lKspectibn D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 0 ao is" 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 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/Altemative 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(descri be): S s•3113 Tioe5omcial iris pecticnForm Subsrrfaae Se%egeDisposal System•Page 8of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis posal System Form orm -Not for Voluntary sP Y t ry Assessments 19 `f l o 00,P-f J Ory ne• Property Address inforriiation is Ow ner's Name required for every page. Cdylrown State Zip Code Date of Ins coon D. System Information (cunt.) Approximate age of all components, date installed if kno )and source of information: 11 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): J l0 � 7, 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): 113 Dept h bel owde: feet Mate' 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: Sludge depth: We-W13 Title 50ffiaal Iris pectin Form SubsWace Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �I Co�✓1Qr� 1� Property Address ^ n� �'"+" �D �✓��f Ow ner Ow ner's Name / /S information is requiredforevey C10✓1 page. Cityfrown State Zip Code Date of Insfectiori Do System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle / I How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PL'i !�!61 042) (le C 0 V'1 0^7 e G7K G.� RNG 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 Gyps.3M 3 Title 5 official lnspectim F—Subsirfaw SevMe Disposal system•Page 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / Co✓l 0?rf Qd Property Address (�L 60 i fief inf rmnerafion is Om nets Name required for every C2 yr ��2- 14 hr 3.Z page. City/Town State Zip Code Date of nspe tion D. System Information (cont) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, e%idence of leakage, etc.): a 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 worldng 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 t5m,3M3 Tiue50ffidd Impect-F—Subsurface SevMeDisposd System.Page 11 of 17 F' r Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L f CO rn O-Pl f lQ d Property Address ON innerformation ON ner's Name required for every -,/J 0;4 3.2- y h - Page• Cityrrown State Zip Code Date o Inspe tion D. System Information (cons.) 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.): ev /t/V so l �s Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ Now Alarms in working order. ❑ N Yes ❑ o Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ns•3113 Title 50rficiel Inspection Fame Submeace Sewage Disposal Stem•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal g sp System Form -Not fior Voluntary Assessments Property Address owner 41,e1' hformation is Owner's N2me required for every �e vt4e..-ti , 4 Z-6 page. CQyf row n State ZO Code Date of Inspection D. System Information (cony.) Type: UCP- So L-) - -� S�� CA, f ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): fh tZ Vt C� i 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 t5ns•W3 Tiitle50fleial InspectionFomc Substrface Sewage Disposal System-Page 93 c(V Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address L�l ' �►n� sL co�'Il2�t inforntion is CW ner's Name I required for every C214-t�/✓i 1� 11F1 (� page. C�tylTown State Zip Code Date of in pection D. System Information (coat.) 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.): t5rrs 3h3 TiUe50f5da11nspecbcnFa m Subsirface Sewage0ispoW Sy;bm•Page 14 of 17 Commonwealth of Massachusetts ,p- Title 5 official Inspection Form Subsurface Sewage Disposal System Form -blot for Voluntary Assessments 1// cooivee'.r �2� Property Address 12 9/ — L_ 4r.e f Ow ner Owv ner's Nameinfonration is K required for every _1— page. Q.ty/Town State Zip Code Date of 4rispec' n D. System Information (cunt.) 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 Fiz 0'v I 16 9-3- 4 t5irs-3113 Title5Official Inspection Form Subsurface SeeageDisposai System*Page 15d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 01414 Property Address Ow ner L- I-I/'o 'el o f information is Ow ner S 1V8Rie required for every page. uryllOW° State Zip Code t]ate of spection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. I� 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,I ai Board of Health-explain: zr Gas f 90 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descrjb� how you essAablished the high ground water elevation: �� u CI 'T�7 floc i` a v►) Gi r� J /0 C a a ' 49 .,C e 4 p�i/t• !/Yi�TiV— Before filing this Inspection Report, please see Report Completeness Checklist on next page. t.Sm•W13 Tive5orfiaial Irspecfion Fame Sufsuface SeaageDispcsM System-Page 16 of 17 Commonwealth of Massachusetts ..W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary As meats CO019�/f � Property Address Owner �quiredfo is Owner's requ�edfotevery page. Wfrown State Zip Code Date of WpeoWn E. Report Completeness Checklist LJ Inspection Summary: A, B, C, D, or E checked ;/S� em Summary D(System Failure Criteria Applicable to All Systems)completed Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Sm-Y13 TMe5Of6ad Mspea9MFam[SUbsWSMSewa9eo System•Page 17d 17 L•. COMMONWEALTH OF MASSACHUSETTS v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRS. OIOI\, . \ y ONE WINTER STREET.'BOSTON, MA 02108 617-292-� WILLIAM F.WELD UDY CORE Governor Laurie Pim alro S v ~ Secretan• ARGEO PAUL CELLUCCI "t[jJ� D 1 B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO �� (V Commissioner PART A. CERTIFICATION �+ ` Property Address: 4i Co.nri rs, GR�I':. ,= Centerville2:.; Address of Owner: 34.1 d.. ' Date of Inspection: � `I Q MA (If different) Sarid.WlCh Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Servi c Mailing Address: PO Box 1089 , Centervi 1 1 L- , MA 02632 Telephone Numbers 5 0 8 ` 7 7 5—R 7 7 6 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 1,/Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Q Inspector's Signature: 1 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check ( B, C, Or D: j SYSTE PASSES: �/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] S TEM 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. Indicate es, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Anww.magnet.state.ma.us/dep ('j Printed on RecyGed Paper a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Al- C;o:nnor_E,!,Rd . ,,'Center--Ville Owner: Laurie Piment i Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) r'due t).a broken, settled observations: uneven distribution box. The system will pass inspection if(with approval of the Board of e . broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due 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 C] FULER 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 the public health, safety and the environment. 1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Connors Rd.. , Centerville Owner: Laurie Piment 1 Date of Inspection: �-"�4 c DJ SYSTEM FAILS: You ust indicate ei; ,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or Icesspool. LStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. I Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LAR E SYSTEM FAILS: You m t indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in additign to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requ rements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Connors Rd.. , Centerville Owner: Laurie Pimental Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following- Yes No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _J_/ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address41 Connors Rd.. , Centerville Owner: Laurie Pimental Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:-1/ 4 g.p.d.bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):/LC) Laundry connected to system (yes or no):e2 Seasonal use (yes or no):�� 1998 43 , 000 gal Water meter readings, if available (last two (2)year usage (gpd): Sump Pump (yes or no): 1-1 C) , Last date of occupancy: COMMERCIAIJINDUSTRIAL: Type of stablishment: Design fl w: gallons/day Grease tr p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTHE : (Describe) Last d t occupancy: GENERAL INFORMATION PUMPING RECORDS and ource of information: /v .a System puna0ed as part of inspection: (yes or no)_,,d, If yes, volume pumped: eallons Reason for pumping: TYPE O�YSTEM l/ 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)A1116 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address; 41 C onnora Rd. ,Centerville Owner: Laurie Pimental� Date of Inspection: ..le-4 O BUM ING SEWER: (Local on site plan) Depth low grade: Materi I of construction: _cast iron 40 PVC_other (explain) Dist ce from private water supply well or suction line Diam ter Comr ients: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) pP Depth below grader Material of construction: ✓concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: `k & 16 Sludge depth: is r Distance from top of sludge to bottom of outlet tee or baffle:�/-f— Scum thickness: t. i Distance from top of scum to top of outlet tee or baffler ; Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: �� - Comments: (recommendation for pumping, condition of inlet and outle.tees or baffles, depth oIquid level in relation to outlet invert, stt ctur, l integrity, evidence of leakage, etc.) '&1- / � � 0''/ r �.- X > y s- fA- �T c u GR SE TRAP: (loca on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime ions: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dist ce from bottom of scum to bottom of outlet tee or baffle: Da of last pumping: Co ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integ ity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4.1 Connors Rd.. ,Centerville Owner: Laurie PVF tal Date of Inspection: �Z_/L T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (lo to on site plan) Dept below grade: Mater I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime sions: Cap ity: gallons Desi flow: gallons/day Alar level: Alarm in working order_Yes; _ No Date f previous pumping: Com ents: (con it of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:-- Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (loc to on site plan) Pumps in working order: (Yes or No) Alarn is in working order.(Yes or No) Comi nents: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Connors Rd.. , Centerville Owner: Laurie P'Ty al Date of Inspection: oZ~I 7 �} SOIL ABSORPTION SYSTEM (SAS):_L (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: .� . leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (not condition oil, signs of hydraulic failure, level of ponding, con ition of vegetation, etc.) CESSPOOLS: _ y (locate on site plan) Number and configuration: Depth-top of liquid to inlet inve Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Co ments: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) P VY:_ (I sate on site plan) M terials of construction: Dimensions: De th of solids- Co ments: (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Connors Rd.. , Centerville Owner:Laurie Pimental Date of Inspection: i SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) w f (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4.1 Connors Rd.. , Centerville Owner: Laurie Pimental Date of Inspection: );.--14 r"'v$ A Depth to Groundwater / Feet Please indicate all the methods used to determine High Groundwater Elevation: y Obtained from Design Plans on record `,/Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 50 .00 No. � Fee .•..:: THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Migpoml *potent Construction Verna Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 41 Connors Rd. Owner's� A�Igj�f1C @NOR d Assessor's Map/Parcel Centerville Sandwich 888-5932 `Zs-/ — O Z 7_ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm E. Robinson Septic Sery P.O . Box 1089 Type of Building: 3 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature airso Al ions( n wer hen c le remove old cesspools ins°4a�� a , � ga� tangy, p�o chambers 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 by this Bootd Signed - Date �/,-7—g Application Approved by Date ///--/-7- 9.7 Application Disapproved for the following reasons Permit No. .7 Date Issued �— j Y J No. 5 0-0 o Fee / THE COMMONWEALTH OF"MASSACHUSETTS Entered in computer: ✓ I - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for ;D -4pozaf *pgtem Construction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lwarie tal Location Address or Lot No. 41 Connors Rd. Owner's A ,A�Igji fle6NoR d + Centerville Assessor's Map/Parcel 7 S/ _ O Z ? Sandwich 888-5932 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm E. Robinson Septic Sery P.O. Box 1089 centervi _ o Type of Building: 3 _ Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building IJdyd£P•r ns �3 Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 'Type of S.A.S. Description of Soil sand. Nau remove old. cesspools nSfjpgj "aioj&(qn�fi) ynde&Sple precast stonedpaeked leaeh 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 by this Bo oSXeWth. Signed Date Application Approved by Date 7— 9 Application Disapproved for the following reasons Permit No. YP7-73r Date Issued 7-!n ————————————— ———— .r -- Pimenta ,T C OM,�` ""0NWEA H OF MASSACHUSETTS �BARNSTi4 1 , MASSACHUSETTS Certificate of Compliance x THIS IS TO CERTIeFY,t4aOt VjRg-&�cg P�pgf2kjn Constructed( )Repaired ( )Upgraded( ) Abandonec}�(1 lay 1-niurs Rd __ at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 r- 736!�5' dated h"' 7— 9 Installler Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 4,-— qj�z Inspector --- ------------------------------- No. r Fee 50.00 Pimental THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mio paa[ *pgtem Construction Permit Permission is hereby granted to%prstRr6t � epar0{ r� (vi)Abandon( ) System located at 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 be completed within three years of the date of this permit. Date: Approved by �` �� NOTICE: This Form Is To Be 4ed or the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated ��`/ 7 !' concerning the property located at 41 Connors Rd, Centerville, meets all of the following criteria: where are no wetlands within 100 feet of the proposed leaching facility. 'i here are no private wells within 150 feet of the proposed septic system. Pfhere is no increase in flow and/or change in use proposed. 'here are no variances requested or needed. If the proposed leaching facility will be located with 250 feet of any 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 Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) 30 �. SIGNED: �/ �/� DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). G o ci l '120�� TOWN OF BARNSTABLE LOCATION 0-ti SEWAGE # 211- VII LAGS_ ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NO. /1/��i�L_C z.� i� F,-77 Z SEPTIC TANK CAPACITY r LEACHING FACILITY: .ram— [, (type) _ (size)A� NO.OF BEDROOMS .�I- -,3 BUILDER OR OWNER PI /,W/— PERMIT DATE: /1—/7— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leactlifig Facility Feet Private Water Supply Well and Leaching Facility (Zanells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any west within 300 feet of leaching facility) Feet Furnished by I I L� .6� �,.� CSh �- 07✓ / l'TOWNOFBAMSTABLE LOCATION 4'Q -4-A,��* ZeV SEWAGE # � ' 23 V VILLAG ASSESSOR'S MAP&LOT PV/9 b,1 7 INSTALLER'S NAME&PHONE NO. /1 y"�L� a` 7 7J'—F Z7 SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size)A NO.OF BEDROOMS BUILDER OR OWNER '/ 0145 Ar.01 r104 PERMIT DATE: 5' COMPLIANCE DATE: let"I -9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leac 'g Facility Feet, Private Water Supply Welland Leaching Facility (If any ells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any we ds exist it within 300 feet of leaching facility) Feet Furnished by a Lit) \� 37' v --