Loading...
HomeMy WebLinkAbout0080 CONNERS ROAD - Health 80 CONNORS RD., CENTERVILLE A= UPC 12534 No. 1-153LOR HABTINO$, MN l No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for M' OsaI 6pstem Construction Permit Application for a Permit to Construct( ) Repair ; Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. < Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 't � Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. C�'1 roax Type of Building: 7_;U4 O1,61 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 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Im O- Date last inspected: Agreement: The.undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board •- Health. Signed Date Application Approved by Date 010' Application Disapproved by Date for the following reasons Permit No. an) Date Issued - --------------------------------------------------- - - - -- -- +fy,'.^`-i1.,. ""•1-..,. . w yl;^'•'^ ..ri 4;., _ ... �f �..�-�..h w- •, ,..._'/B.-•r9iti+,..-..''x."� r.�'Y:"+•.. .r .. _..4.•.�......r-"'-^ hie No. ✓f �;y r Fee T THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes l�lflLatiDn for " is osat �pstPttt Construction permit � Application for a Permit to Construct( ) Repair(/pgrade( ) Abandon(' ) ❑Complete System ❑Individual(Compo`ents Location Address or Lot No. QU sCd Owner's Name,Address,and Tel.No. `ppQQ y Assessor's Map/Parcel Ciy1Aejv'Rx, KA A ZE M ZQ..*J}� Installer's Name,Address,and Tel.No. ` Designer's Name,Address,and Tel.No. a?4 S (1, &LAL. N Type of Building: -7-7'4 { 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 a Date Number of sheets Revision Date c Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) &pka g Q"L-xf-)X Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of y Compliance has been issued by this Board>of Health. Q Signed - Date \ i Application Approved by Date Application Disapproved by Date for the following reasons i Permit No. �.Q r�''�' Date Issued "? a THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS r (Certificate of Compliance THIS IS TO CERTIFY,that the Onsite Sewage Disposal system Constructed( ) Repaired(� Upgraded( •..) z Abandoned( )by at �nnr1 A--. IeE�I' ( _9jn 4 rV 1(U� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nor .�--�rated ­2 1 " 4D Installer /`�� �d .� Designer #bedrooms 1 Approved d-e§jgri gpd The issuance of this permit shall not be corlstrued as a guarantee that the systemwill fimetiosigned. Date P Inspector --------------------------------------------.--_- ---------------------------------------------------------------------------- - No: Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Di��lO�aY �p8te Construction VPrlliit Permission is hereby granted to Construct( ) Repair(L Upgrade( , ) Abandon( ) System located at C n i (P1�4YI Y and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her,duty to comply with :.Title 5 and the following local provisions or special conditions. Provided:Construction must be comp eted within three years of the date of this perm�t7h" --- Date � / Approved by,,, t r ' Barnstable oF1KE Town of BarnstableAMW, caCill"Regulatory Services Department � IIARN5fA8LE. +*' MA$S. Public Health Division qjA i63q. ♦4i T�OMa+A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 0232 July 10, 2018 ZEVITAS, JOHN T & EVERDINA 80 CONNERS RD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 80 Connors Road, Centerville, MA was inspected on 07/10/2018 by Darrell Stone, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH ►� 6 Tho as Mc ean, R.S., CH Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\80 Connors Centerville.doc Town of Barnstable Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA"02601 ofcc: 508-862-4644 Richard ScA Diroctor FAX: 508-790-6304 Thomas A-McKcar,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAMED.SYSTEATS (Town Code §360-44 and Title V: 310 CMR 15,000) _ .An`z'marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA - ❑Discharge or ponding of effluent to the surface of the ground w ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. _. a Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑.Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Singletcsspool " Vk6­ny"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Loll Repair deadline: WISEPTIC0EADLINES TO REPAIR FAILED SYSTEMS,doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r..a M 80 Conners Rd � Property Address John& Everdina Zevitas Owner Owner's Name I information is required for every Centerville V/ MA 02632 6-27-2018 : page. CityTrown State Zip Code Date of Inspection pay 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, use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection rea Company Name P.O. Box 1466 Company Address �r .> Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Pass ditio ses ❑ Fails ❑ N ds u her o Local Approving Authority 6-29-2018 ctor'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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 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): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface,Sewage Disposal System Form- Not for Voluntary Assessments �M 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 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 side walls are rotted out and soil is filling the D-box. ❑ 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)(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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every page. City/Town State Zip Code Date of Inspection B. 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 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 to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every 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. 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® ❑ available note as N/A ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® Ej 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): NSA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 bedroom residential dwelling 2 Number of current residents: Does residence have a garbage grinder? ® 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 ® No Current 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Y Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 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: 11/2016 Discount Septic Pumping (508) 240-2500 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): t5ins•3/13 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 �M 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every 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: 1988 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 26"+l- Depth below grade: 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.): Apparent good condition Septic Tank (locate on site plan): 16" 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 Dimensions: 2500 gallon H-20 6" Sludge depth: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every page. City/Town 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 28" 2" Scum thickness 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? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet cover to grade Normal liquid level No sign of leakage Sch 40 tees Recommended next maintenance pumping within 1.5 years Recommended maintenance pumping every 2-3 years 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 ¢Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. CitylTown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M ,�0 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville MA 02632 6-27-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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.): H-20 DB-9 Grade to box 34" Cover to grade 2 outlets Dry Side walls rotted out Lots of sand in the box Needs replacement 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w., 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ 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.): 6, H-20 (4x4x4')chambers with stone Grade to chamber 67" 2 Covers to grade Bottom 115" Dry No sign of hydraulic 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. City/Town State Zip Code Date of Inspection De 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 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 FRONT Fg E j(D-1. �tiv4� -J2 GC2raciQ IL i I i- H I ).o-- 2 25 - 0 �6-0 3 �U- 4 ,:, 0, 0 ! 6 ! i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r-- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is required for every Centerville MA 02632 6-27-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 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: Bottom of SAS 115" Back yard property slope to 163" NWE Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts A Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Conners Rd Property Address John & Everdina Zevitas Owner Owner's Name information is Centerville required for every MA 02632 6-27-2018 page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f ,off CONMONZ EAI.TH OF MASSACHL;SETTS _ EhECumE OFFICE OF E:N'VIRO\-mE\TAL AFFAJRS F _ DEPARTMENT OF ENVIRONMENTAL PROTECTION OXE R'LMR STREEZ7. BOSTON AL;0210t t617t 242-550v TRU DT COL' Secre:ar.v ARGEO PALL CELLLCCI DAVID B STP.-I?S Governor Comzstiss:one- � SUBSURFACE SEWAGE DISPOSAL SYSTEM SISPECTION FORM PART A CERTIFICATION Property Address: Name of Owner Rd M a r t h a 11 Address of Owner: Dote of k$&,Cpnnors Rd. , Centerville Name of Inspector:(Please Print)Wm. E. Robinson S r. I am a DEP approved s errl inspector to Section 15—W of Tide 5 9310 CMR 15.000► �rnp,r,y : Wm. E . Robinson reepttic Service MaSrngAddress: PO Box 0 9. Centerville n Telephone Number: CERTIFICATION STATEMENT 1 certify that I have person Illy inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete its of the ti a of inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on-site wage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails f� Inspector's Signature: / a, Date: The System inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS OCT 2 0 2000 VOOFWWABU N t KALTH oEpT. I ! . t xe11Se0 9/2/98 Paprlorn C: ­-lei o-ltecvc:rd Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) NgwrtyAddress: $0 Connors Rd. , Centerville awry: Ed Marshall Date of Inspection: C? INSPECTION SUMMARY: Check 4�, B, C, Or D: A.zSYS;criteria PASSES: ve not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure not evaluated are indicated below. COMMENTS: B. YSTEM 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 lattached)indicating that the tank was installed within twenty 120)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 H the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipets)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more then four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed _"'evlsed- 9/2/96 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Connors Rd. , Centerville Owrw: Date of Ins�et93A FF 1� rshall `3 43_01-e) 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 f11(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) YSTEM 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 AND SAFETY AND THE 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 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). 31 OTHER rev1: se Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Owner: 80 Connors Rd. , Centerville ' Date of Inspection:Ed Marshall D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). 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. RGE SYSTEM FAILS: You m st indicate either "Yes" or "No' to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The own r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of he Department for further information. re'v-sed 5%2/5t Pagc4or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. ,q PART B CHECKLIST Property Address: 80 Connors Rd, Centerville Owner: FF Date of Inspettf1:Marshall 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. L. _ As built plans have been obtained and examined. Note if they are not available with NIA. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. L/ _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. Y _ 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: Existing information. For example, 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)) The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanr4i�-0f SubSuriace Disposal Systems. re1'_se,4 C��G�SC Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ►roperty Address:80 Connors Rd. , Centerville Owrw- Ed Marshall Date of Inspection: �r ati FLOW CONDITIONS RESIDENTIAL: Design flow:e46 yg.p.d./bedroom. Number of bedrooms(design): Number of bedrooms factual): ,p Total DESIGN flow r e y Number of current residents: /¢ Garbage grinder lyes or no): � Laundry(separate system) lyles or no)-A,,� If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):-14--0 Water meter readings, if available (last two year's usage (gpd): 1999 176, 000 ci?l Sump Pump(yes or no)-/f- O 1 998 128,000 gal. Last date of occupancy: #A COM ERCIAL/INDUSTRIAL: Type o establishment: Design low: god ( Based on 15.203) Basis of design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d to of occupancy: OTH :(Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /!i A . System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval 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) �. revised 5 2 PaFc 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icondnued) 'ropeny Address: 80 Connors Rd. , Centerville OW11ef: Ed Marshall Date of Inspection: BUl 'NG SEWER: (Locate n site plan) Depth low grade:_ Materi of construction:_cast iron_40 PVC_other(explain) Dist ce from private water supply well or suction line Diam ter Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:�l Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_(Yes/No) Dimensions: Q bD Sludge depth: y—�•• r Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: e L 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 dimensions were determined: n 'omments: (recommendation forpumping/ condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, s;ruc urel integrity, evidence of leakage, etc.( L SAS �b� ��� I �^ 7� f J G GREAS TRAP: (locate o site plan) Depth be ow grade:_ Material i f construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) _ Dimensio s: Scum thi kness: Distance rom top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of st pumping: Comm ts: (reco endation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage, etc.( rev = Gi 2/90 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 6roperty Address: 80 Connors Rd. , Centerville owner: Ed Marshall Date of Inspection: TIGH1 OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b ow grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alarm eve]: Alarm in working order: Yes_ No_ Date revious pumping: Comme s: (conditi 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, evide ce of solids carry ver, evidence of leakage into or out of box, etc.) G,' - D /S PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No)_a�''� Comments: (note condition of Dumq rhimber,_condition.nf-ymps and appurtenances,etc.) revises 9/2 /9c Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eoribmeed) er Owner:op Address: 80 -Connors Rd. , Centerville Date of lrtspe�n:Marshall�� 3- SOIL ABSORPTION SYSTEM(SAS):—),� (locate on site plan, if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, 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: (note condition of soil, signs hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) r � 0 5V CES O LS ' _ (locate o site plan) Number a d configuration: Depth-top of liquid to inlet invert: Depth of s lids layer: )epth of s um layer: Dimension of cesspool: Materials f construction: Indication of groundwater: nflow (cesspool must be pumped as part of inspection) Comment (note cond uon of soil• signs of hydraulic failure, level of ponding, condition of vegetation, etc.) jDepthsolids: e plan) onstruction: s: Dimensions: n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) Noperty Address: Jwrwr: 80 Connors Rd. , Centerville ante of Inspection: Ed Marshall SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) � l rell" Sea; D �b 0 b� ) 1 `J � Page 10 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) ropertyAddress. 80 Connors Rd. , Centerville Owner: Date of brapeciad Marshall NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole. basement sump etc.) Determined from local conditions ",/Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Musa be completed) revised 9/2/9E Page 11of11 DATE;_----- 0__-- PROPERTY ADDRESS: 80,_Connors Road ------------------------ On the above date, I Inspected the septic eystem at the atpVC000drrss. This system conslsts of the following; • ' 1 240Q "OF 1 . 1 -2500 gallon septic tank. �°10 2. 1 -Distribution box. 3. 6-4 'X4 ' gallies in seriejs. ^ Based on my Inspection, I certify the following condltlonv 4. This is title five septic system. ( 78 Code ) .The septic system is ,in proper working order at the present time, 5. Wates water is below inert pipe.too the first galley is 30" all of the others are dry. SIGNATURE: Name:_,La,-lUsstotq,r _)J--______ Company; Joae,ph_P _Macomber_& Son , Inc , Address;_ Box_66___---------- , Cantervi11a Nay_02632-0066 Phone:___ ------- THIS CERTIFICATION GOES NOT CONSTITVTE A OVARANTY OR WARRANTY JOSEPH P. MACOMBE:ta & SON, INC- Tsnks•C9r;>'pools•Lhflolds Pumped i� Inslsd Town Stwor Conotlons P.O. Box 66 5•JJ3 toryll7, A 026J2.0066 OG� -i ESQ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COXE Sec»terry ARCEO PAUL CELLUCCI DAVID B. STRUHS Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Property Addnass: 80 Connors Road NamisofownwEileen Marshall Centerville as 02632 AddrassofOwnw: Dru of inspection: g 2 5�b( Nart,. of moo,: (Pw&"PKnt) oseph P. Macomber Jr. I am a DEP approved siystarn Inspector pursuant to Section 16.340 of Thie 6(310 CMR 16.000) ,yµ. .: Jose:ph P. Macomber & Son Inc. Mairsg Addrew: o x e n e r v i e Ma. Q2632-0066 T"aphone I�urnber — — CE3tT11RCAMN STATEMENT I certify that I have personally Inspected the sewage dlsposaJ 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 ma,mensnce of on-site sewage disposal systems. The system: 4 ssaa _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Falls Irtspecta's Signature: ` Date: The System Inspect shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wlthln 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 sbali submit the report to the appropriate regional otflce of the Department of•Environmeruld Protection. The original should be sent totw system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 psgtIor►i Printed on R"ted Piper SUiSURYAtx SEWAGE OLS►OSAL SYSTVJ INS►£CT10141 FO" PART A CtRTViCAMN (oor*d J04Q �,00.rtyAaar.as; 80 Connors Road Centerville,Mass. ow^'r Eileen Marshall Darts of ti`°"s«': 9/2 5/0 0 ks►£Cr.ON SU#ALLkRY: Ch ck A. 0, C. Of D' A. Ysro+PAS A. I hwvo not found any Informadon wNch In CC$$that :trey of the f+lluro cor4tlona described In 310 CMR 14.303 eyl.&L Any ti crhoris not ovsivated we Indicotod bolow. $. SYST4s CONOMOuA.LLY PASSES: �_ Om w more oy$tam eomponontw u do#oribod In the 'Condid" ►sa#' socdon nod to be ropiaood or repaked. The oyetam. . compJotion of the rspiacoment w repair, w approvod by the Soard of Health, will paww, tndcete ye#, no, w not determinod(Y, N, w NO). Ooscribe baalw of detwmlrtation In all Uutarwos, If 'not detarminwd', expJaLt why not The eopdc tank la metal, uriess the owner w equator has provided the system Lnwpeotw w Cuedau oOPY f I t1►. tnwpKv• 41pon 20) ou$prig to CompUancs (attached) Indicadnp that the tank waw kutaLed within twenty I Y the oepdc tank, whether or not metal, is cracked, struawl"y unwound, show* substantial Wilvadon w *a or+ failure Is Imminont. The system will paws kupoodon If the oxlsdnp sopdo tank Is replaced with a comOYtn7 approved by the $card of Health. t&tjo Water evel bserved In the Sr duo to a broken, totter d orun v en dl#trtbutlonlbox.oThe system wW passulrtapo"on if(whh approvaJ o Vw Beare 0 r Health). broken pipe(#) we replaced obswcdon la romoved distribution box Is levelled w replaced Al The #Mom required pumphtq-'n th+n i°�tr^we yeartSuo to broYemw obctyvotrd pipe(#). The*y*t'T^ `=' Inpecdon If(with approval of the Ioard of Hoalth): broken pipe(#) we roplacid obstruction Is removed h�elof11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART A CER,nFICJITION (contizuwd) ft.p.MAdraa3: 80 Connors Road Centerville,Mass. ow„«: Eileen Marshall 0-- of``P`6`9/25/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Ji /6 Conditions exist which require further •v&luadon by the Board of Health In order to determine if the system Is N111119 to protect ttw public health, safety end the environment. 1) SySTDd WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CUR 16.303 (1)(b)THAT THE SYSTEM IS NOT FUNC71ONIN0 IN A MANNER WH1CKyAL..PAQ?F.CT THE PtJeUC UEA.LTVLAND 1f:J1FETY AND THE Btt08OkMSNT:: A✓d Cesspool or privy Is within 60 feat of surface water Cesspool or privy Is within 60 loot of a bordering vegetated wetland or a salt marsh. 2) SYSTE)d WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER,IF ANY)Dr:TIEFJAD E3 THAT THE SYSTE64 IS FUNCT10NIN0 IN A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVLRONUDITN TT: 0D The system he+ a septic tank and loll absorption system (SAS1 end the SAS Is within 100 tent of a wrface water wpply or tributary to a surface water supply. AJ6 The system has a septic tank and loll absorption system and the SAS Is within a Zone I of a public wet*( wpplY weU. The system has a septic tank and Boll absorption system and the SA3 Is wlthln 60 1001 of a private water supply wa - The system has a septic tank and loll absorption system and the 3A3 Is lose than 100 feet burlor 60 feet or me hem a privets water supply well, unless a well water analysis for collform bacteria and volatile organic compounds 1"ca100 trot tAs wall Is free from pollution from that facility and the presence of emmonloVogo n not valid).- and nitrateBogen Is equal to or less than 6 ppm. Method used to determine distance �4 (appr 71 OTHER 0 Psxe 7 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART CERTIF}CATION (continued) P+ove�y Addles'; 80 Connors Road Centerville,Mass. Owrw; Eileen Marshall Dots of VOP*ct—:9/2 5/0 0 D. SYSTEM FAILS: You must Indicate either 'Yes' or 'No' to each of the following: bed I have determined that one or mcr ThetBo rdl Iiof althfail ure n d shouldbecontacted to dateons exist as r min In will be necessary to corr+ct tN talk determinsbon Is Identified w. Y e s No / oornponrtt�dae cto em ovetioeded orvWggodSA&or'cesapd. Backup o}eewags IntohcIWrr r•*Yet+r^ Discharge or ponding of stfluent to the surface of the ground or surface waters due to an overloaded w dogged SAS or cesspool. Static liquid =ear the di %r bulion box + `�!t l^volt due to an overloaded or clogged SAS or cesspod• _� liquid depth In xa+sepeeFl6i'lessstthan 6' below Invert or avallsble volume Is less than 112 day flow. Required pumping more than �J 4 times In the lost Yost�due to clogged or obstructed.pipe(')• —" Number of tlmss pumped Q. f Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. 414, Any portion of s cesspool or privy Is within 100 fast of a surface water supply or tributary to a surface water supplY Any portion of a cesspool or privy is•wlthin a Zone I of a public well. _✓ Any portion of a cesspool or privy Is within 60 fast of a private water supply wall. Any portion of a cesspool or privy Is less than 100 feet but greater then 60 feet from a private water supply well with r —" e well has +nitro9ent�dsnitr to nitr acceptable, ogen.ach copy of well water snafysu tc acceptable water quality analysis- It th -collform bacteria, volatile organlo•compounds, +mmonf. E. LARGE SYSTEM FAILS: You must Indicate either 'Yss' or 'No' to each of the following: The following crltsrla apply to 1ergs systems In addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system Is a slgrtlflc+nt trvsot to health and salsty and the environment because.one or mots of the following conditions exist: Yes No the system Is within 400 fact of a 'urfsce drinking water supply - --- er •te�wrtew� 4'M'eNciu►fIY•... . !/ the system•Is-with 200 {eet of a Nl�ut Y Zone 11 0l • I the system Is located In a nitrogen sensitive ergs(Interim Wellhead Protection Area r IWPA)or a rtt+pped water supply wall) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 16.304(2). Please consult We local re otffce of the Dspsrtmsnt for further Information. Page 4 of II revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORMA PART B C1iECKL13T P,opan•yAddras.a: 80 Connors Road Centerville,Mass. own«: Eileen Marshall Deta of l"+°cdon:9/2 5/0 0 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<ornpo+arAa ka,ua:ao&&n pawtpadJ*Pat•Jaaat:two•wo&"su*tbslYstom haabarowoaltaaq.e..d r rates during that period. Large volumes of water have not been Introduced Into the system recently or as pan of ws Inspection. _ As built plans have been obtained and exemined. Note If they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage backup. The system does not receive non•sarJtary or Industrial waste flow. _ The ske was Inspected for signs of breakout. _ All system components-Mudlno 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 conciltion of bet 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 bean determined based on:- (C _ Existing Information. For example, Plan at B.O.H. _ Determined In the veld (if any of the failure criteria related to Part C Is at Issue, approximation of distance Is unacceptaa 116.302(3)(b)) _ The faclUty owrw (and.oae—p;}•,Jf dUlarant troaLa ear). ua.pzo-IdaefxL:h larntr -floaon gip=;•r�--i- SubSurface Disposal Systems, revised 9/2/98 ftiiasorii I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Deis of 4►spectSort: FLOW CONDMONS RESIDFNT1Al: Design flow:a_g•p•d•/bedroom. Number of bedrooms (design): of bedrooms(actual);. Total DESIGN flow 60 Number of current residents: Garbage grinder(Yes or no): Q/b _ Laundry Isepuste system) l es ot�:__ : If yes. sspasaia�rtapaction<raQulrad Laundry system Inspected lye or no) Seasonal use (yes or no): �9 f��� Wets( meter readings,It available (is$t two year usage (gpd):f / '�Oas9 Sump Pump(yss or no) Lost date of occupancy: r oMMERCtAL/INDUSTR1Al: Type of estsbllshmsnt: A� Design flow: M god I Based on 15.203) Basls of dsslgn flow Orease trap present: IYas or no) Industrial We"Ito Molding Tank present: (yes or no)169 Non•saritary waste discharged to the Title 6 system: (yes or no)m _ Water meter readings,If available: Lost date of occuponcy:—,VA OTHER:(Describe) f Last dote of occupancy: GENERAL INFORMATION PUMPING E ORDS an�d our of Information: System pumped as part of Inspection: (Ye+ or no) If yes, volume pumped:1_gallons Reason for pumping: TYPE OF SYSTEM V% Septic tankldistrlbutlon boxlsoll absorption system A) _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous Inspection records,1f any) A IIA Technology atc. Attach copy of up to dote operation and maintenance conuact ja Tight Tank 41,4 p Copy of DEP Approval Other AO of all co ponents. data I t+WadiJf known)and source of�wlorrttsdon: gV + 'owG/'V 6a Swage odors detected when-arriving at the site: (yes or no) _ revised 9/2/98 Pace 6 of 11 Yi < I TOWN OF BARNSTABLE ! I LOCATION tl y ,,, v �„2s LQ SEWAGE #Yg� /rS 'i ! VILLAGECC15 NTr /L�/ � ASSESSOR'S MAP 6i LOT 5 INSTALLER'S NAME & PHONE NO.,��� N 77 .5 . SEPTIC TANK CAPACITY S d C j LEACHING FACILITY:(type) G.4 /�e y(�A�'�t (S�)1 �> `3 O X/G PRIVATE WELL OR PUBLIC WATER NO. OF BEDROOMS I BUILDER OR OWNER /w Jw v tv DATE PERMIT ISSUED: (V � g DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No �-y- l �� P7 � 1 Y ! I � y SUBSURFACE SEWAGE DISPOSAL'SYSTEM WSPECTION FORM PART C SYSTEM WFORMAT10N Icon *-Wd) Property Address: 80 Connors Road Centerville,Mass. Dan : Eileen Marshall Dou*II-590c'ti°rt:9/25/00 BUILDING-SEWER; (Locate on site plan) Depth below grade:_ej) Material of construction: _cast Iron Z0 PVCdp other (explain) A01t Distance tromjrivate water supply well or suction line dL '71' Diameter V_ Comments: (condition of Joints, vandng, evidence of feakage,-etc.) Joints appear SUT1C TANK �* $ llocats on she plan) �/W Depth below grado�f Material of construction: concretotl0 metal/�Flberglasa�✓t Polyethylene*Mother(explain) if tank Is fnetal, Ile/t ape is,&gs.conIVmed by Certificate of Compllanc#,M& (Yea/No) „ Dimensions:,'/o7tt7 Sludge depth- Distance from to sludge to bottom of outlet toe or bells 2&. Scum thickness: Distance hom top of scum to top of outlet toe or bafflo: � Distance hom bottom of scum to bottow of outlet tlletto o r bafflo:2�l.L 2A' - Mow dimensions were detsrrnlnid:/- - GL__ Comments: irecommendadon for pumpinQg,�, condition of Inlst and outlet tees or•bsfflss, depth of liquid level In relattQnInl dude] Ou�lp�+t rea«+togrrty. evidence of leakage, etc.) HM the septic L lk le tees are in Licluid depth at thet rr Tile tank is s ruc GREASE TRAP: e tiocste on alto plan) Depth below grade: Material of construction toncrste(i metal Fibs rglssv✓RPolysthylonyAdother(axpialn) Dimenslons: Scum thicknoss: Distance hom top of scum to top of outlet too or befflo:A& . Distance from bottom of scum to bottom of outlet too or•bsff1o:_'d9 Date of lost pumping: Comments: (recommendation for pumping, condition of.inlst and outlet tees or baffles, depth of liquid level In relation to oudot Invert sauctural Intogrtry. evidence of leakage, etc.) reas 11 e revised 9/2/98 Paee7or11 SVSSURFAU SEWAGE OLSP03AL SYSTEM%N31"E ON FORJA FART C SY3TIEM WFOR"TION (cardn+oQ1 80 Connors Road Centerville,Mass. O.wTbw: Eileen Marshall 0.os of lr,ape+ +: 9/2 5/0 0 no)fT OR HOLDING TANK:(Tank rrwst be pumped prior to, or at Um* of, Inspection) Ilocste on site plan) Depth below grsdrAg Materiel of con41LrycUon;Xconcr•t44gm#%&0 Fib orpla►s4/4►olyvthylent4goth►rt.xplaln) A Dimensions: AU Cspoclty: gallons Design flow: g►Ilonslday Alarm present Alarm level: Alarm In working order:Yss/H Nooj�f Date of prev,oua pumpingt _A� Comments: Icondoon of(riot tee, condUon of ►larm and float switch*$, etc.) Tj,,ht et are no ra Ant DISTRIBVTION SOX:z Uocste on 0II plan) Depth of liquid level above ovdst Inverl:�Q� Comments: ee, LL I e II I*vel,a d distribution Is equal, eviden car Ids carryovN, �oMeviidencetoofWlel►oa, otc. r10`o evidence o or u ion pVWp CMI.1BMAgwe Ilocate on site plan) pumps In working order:Iyes or No) NA Alarms In working order Iysc or Nol� Comments: ,note condUon of pump chamber,condlUon of pump* and ►ppunenonces, etc.) am e htelorii revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' r SYSTEM INFORMAT)ON (costdnued) Propwty Addy.:,:80 Connors Road Centerville,Mass. Owrw: Eileen Marshall Dsu o1 inspection: O SOIL ABSORPTION SYSTEM(SAOS):�9/*!'� �t 'X �'x ' (locate on site plan, If possible; excavation not required,location may be approximated by nonantrusive methods) If not located, explain: Type: Isaching pits, number:d ������777777pppppp leaching chambers, numbe��c,�/ leaching galleries, number: Isaching trenches,numbe(• length; leaching fields, number, dime dons: overflow cesspool, number: Alternative system: /Vw c _� Name of Technology: fr rTe/." Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil• condition of vegetation, etc.) Loamy sand to pg8j um fine RAnH N=cigncnf h�ydy-aij i o failure. or pon ing. Soils are drU_ VAgatai-inn i a nnrmail� CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Inlet Invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: Inflow Icesspool must be pumped as part of Inspection) Cesspool's are not resent. Commenu: Inois condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc.) Cesspools are not present_ PRIVY:41blve (locate on site plan) Materials of construction: /U/Q D(menalons: '4401 Depth of solids:,d2,e-- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) Privy is not p racAni- revised 9/2/98 Psge9orii 3VL3VRFACi SEWAGE DISPOSAL 9Y9TO4 L"PtC OW KFW PART C 3 tyiTFAI W/ORJAATVON(oondrwo4) 80' Connors Road Centerville,Mass. Owr-m.: Eileen Marshall 9/2 5/0 0 SKETCH OF SEWAQE DISPOSAL SYSTEM: Include des to el Iesst two permanent reference isndmuks or benchmarks IOGete ell wells wlthln 100' ILocste where publlo wetsr supply comes Into house) I\� '�Oi ' b e l ' 0 onr�ers• �d � Ili Pete 10 of 11 .revised 9/2/98 i SUBSURFACE SEWAGE DtSPQSAL SY3TO4 WS►EC'nON FORIA PART C S? 3Y3TOA WFORIAATION (condn►e4l Irope►ryAddr— 80 Connors Road Centerville,Mass. Own«: Eileen Marshall Deu of kup.ctson:9/2 5/0 0 NRCS Report morn• Soil Type_ Typical depth to groundwater USOS Date web►Its visited Observation Wells checked Oroundwaler depth: Shallow Moderate Deep SITE EXAM Slope Sudsce water Check Cellar Shallow wells Estimated Depth to Groundwater 7 Chet Ilease Indicate all the method, used to determine High Groundwater Elevation: .'Zootained horn Design Plans on record Ooserved Slte IAbutdng property observation hole, basement sump etc.) _ Oetermined Irom iocal condlNons Checked with local Board of health _Chocked FEMA Maps Checked pumping records hocked local excavators. Installers Used USGS Date Describe how you established the High Groundwater Elevation. QLW be completed) Used Water Contours Map. Gahrety & Miller Model 12/16/94 Pitt It or It revised 9/2/98 .•n1.1T•�nIT^Tr\nIr IO•I.TILT'.'11"w`wTRr\R�ww�I'..��'•\RR.1/��IIIY'. �rY`� • � 1 Il'UNN OF Barnstable BOARD OF HEALTH ,SUI)SURFACF SEHACFI DISPOSAL ,SYSTEM INSPECTION FORM PART D — CERTIFICATION -•�nn•••.•: r-�.n,.��.+•\n\na ww,n�w�wn-n��\�rs�ww�w+w-►�w�wl/w�+�w.w��•wr� ww ��..��. -. i -TY►t OA FAINT CI.CAALY- PROPERTY INSPECTED STREET ADDRESS 80 Connors Road Centerville,Mass. 02632 ASSESSORS HAP , DLOCK AND PARCEL If 251 -022 OWNER' s NAHE Eileen Marshall i PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr, COHPANY NAME Joseph P. Macomber &"Son, Inc. COMPANY ADDRESS Box66 Centerville MA. 02632-0066 $ trfet Tovn or City state t F COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 790 ) 1578 - CERTIFICATION STATEHENT I certify that I have personally inspected the sewage disposa`1 system at >rlecoinmendat' lons his nddress and that the information reported is true , accurate , and omplete ns of the time of .-inspection , The inspection was performed and any regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Sy.s.teoi, PASSED The inspection which I have conducted has not found any information which Indicates that the system fails to adequately protect public health or the environment as defined in 310 CHR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* 1 The inspection wlllcli I haave con acted has found that the system fails to protect the j)tiblic Ilenith and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form , Inspector Signature Data J• a ..... necopy of this ertification must be provided to the OWNER , the BUYER here applicable ) and the AOARD OV HEALTH, y'1.. • If the inspection FAILED, thb owner or operator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 161306 , partd .doc TOVrrd OF.BARNSTABLE LgCATION SEWAGE # J�K VILLAGE ASSESSOR'S MAP& LOT G q INSTALLER'S NAME&PHONE NO. LoT-s L9 y-I1 A SEPTIC TANK CAPACITY 4560 Q011,0nn LEACHING FACILITY: (type) (size(&� NO.OF BEDROOMS BUILDER OR�OWNER) El jP:ej� VYI Q►��5��(1 PERMITDATE: COMPLIANCE DATE: y t� 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 within 300 fee of leas ' g ili ) Feet o Furnished • a COMMONWEALTH OF MASSACHUSETTS > EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR 3 ONE-W=R STREET,BOSTON MA 02108 (617)292- Q WU,LIAM F.WELD 't ECEI`/EO UDY COXI Governor P" MAR Secretar 9 ARGEO PAUL CELLUCCI 1 1 199T D B. STRUH: Lt. Governor Fa TOWNOF ommissione: HEALTH pEPl�IE ®� iI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F s PART A /J CERTIFICATION / Property Address: Coi<K�tS /�+ �'e���to ` (� Address of Owner:,& Date of Inspection: Q3lo ��5 (If different) �q7 4(9�' -e�. S7 Name of Inspector: F-(,t��� (i )e j2c,4� �,JC4 u 1Y0— pZ6o l Company Name, Address and Telephone umber: 7 En v.-row t�,A pc, c.� 2 3734. i`P r9- H O+-06-4_y CERTIFICATION STATEMENT (Soil y I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: t Date: bl b IS� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 A ii Printed on Recycled Paper p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 ' CERTIFICATION (continued) Property Address: ` Owner: n-]U� '�jjt Date'of Inspection: Bj SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribu on box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system ill pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due t roken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALT Conditions exist which require further evaluation by the Bo d of Health in order to determine if the system is failing to protect the public health, safety and the environment. i) SYSTEM WILL PASS UNLESS BOARD OF HEALTH D RMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a su ace water Cesspool or privy is within 50 feet of a b rdering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF EALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANN R THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and oil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank a d soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank nd soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tan and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from at facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: fp Owner: Date of Inspection: 3 job/y D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to etermine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due t an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or availab volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT a to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet f a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zon I of a public well. Any portion of a cesspool or privy is within 50 eet of a private water supply well. Any portion of a cesspool or privy is less th n 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the w II has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic comp nds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large sys/sindition 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 envi onment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 0 feet of a tributary to a surface drinking water supply the system is locat d in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water sup y well) The owner or operator of any su system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 nd 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and 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. 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 existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Ad ress: D© ffd- r_ Owner: - `e ,,2_ Date of Inspection: 4-1-7:7-- 'FLOW CONDITIONS RESIDENTIAL: Design flow: W gallons Number of bedrooms: Number of current residents:_0 Garbage grinder (yes or no):—.To Laundry connected to syste (yes or no):� Seasonal use (yes or no):I Water meter readings, if available: Last date of occupancy: 5 COMMERCIAUI N D USTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water-meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: StAST�vr� Sys em pumped as part of inspection: (yes or no) r.?C) If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: L mv rz Sewage odors detected when arriving at the site: (yes or no)_j)-0 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK:45 (locate on site plan) Depth below grade:ECRA5�e— Material of construction: y_ concrete _metal _FRP—other(explain) Dimensions: C � Sludge depth: 41 7 Distance from top of sludge to bottom of outlet tee or baffle: �;q_ Scum thickness:_ a Distance from top of scum to top of outlet tee or baffle: I tp Distance from bottom of scum to bottom of outlet tee or baffle:— Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) � t , (� KZV� 6 GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: P, _/Loz Date of Inspection:CP 3/ems 6/yam TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: Gallons Design flow: Gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:1�1s (locate on site plan) Depth of liquid level above outlet invert:-,4—jcj 4 Comments: (note if level and distribution i equal, evidence of solids carryover evident of leakage into or out of box, etc.) L2Vt5� �t�y�rly� , t/1�(f11CSt� 0 l�c4 C n p40J[t T Nn 1 n+f- L o o A r.r-it PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible; exca ation 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: C mments: (note condition of soil, signs of hydraulic failure, level of ponding, condition o vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 4, Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' y 3 z 637 s� DEPTH TO GROUNDWATER Depth to groundwater: I V;,_feet method"of determination or approximation: \ cs �,%O)MA CCA4.1ajk" , (revised 11/03/95) 9 No THE COMMONWEALTH OF MASSACHUSETTS ^ 0 —'� BOARD OF HEALTH ..................OF..G.✓ ..r✓..S.?. ../�"---------------_--- ' Appliration for Eliipntia1 Warks T. notrur#iu plMutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: --- __ a ------ - - - ot . ........................................ Ln Address rNo�12t ..... ......................••-------.......-•---•-----..........---- 9w�e Address __ ____ _____________' ...____ __..... .... Installer Address dType of Building / Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....._f_a____________________________________Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures --------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 W Septic Tank—Liquid capacity- s-�'gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No_____________________ Width..............-..... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft, Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p+' ----------------••-----------------------------------------------•-----•-•----•----- --------- •------ ----------------.......... ..... 0 Description of Soil..........................................................••'•-•-•'•---•---._...----•---•--------•------------------•-•-•--•----•-•---------•••••--•'•-•-_...........••- x U -••----•-••••-•••---.....••••••••••••••-----•••-•••-•-••...••-•--•-•-•---•---•••....•••---•---•••••••••-----••-••-•••••-----••••-•--•----•--•--•----••--••-•----•••••••••---•••-•-•----•••••....--•---•. W --••••----••------•---------•••--••-•-•-•••-•-••••---------•-•------••--•-----------------•-•-•--•-•-----------•-f---•----------•--•--•--•-••-•••-•---•••••••-•--•••--•-•-•••••-••••••••-----•-"----••. UNature of epairss or Alterations—Answer when applicable.._%.""'$'r`� J�. a s'o v f.9� T.9 y /J ......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of ITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by n f �the�brd of h �( ( Da Application Approved By.............• ��,h ....--...................................... -•-• -�l(.i' Date Application Disapproved for the following reasons:.............................................................................................................. -•------------------•---......----•---•--•---•--......---•--•----•----.._..------------•---'-..........--•••-------------••••--•••••-••••-'••-••--•••••--•••----•-•-•---••----••---••••••••--••-•''__-'- Date Permit No...` -'_I ------------------ Issued........�/....... ................................ Date No................ ..... Fsa..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /,. r /1, 5- ..... .. ............ :� :fH..................OF......... ......................7 Appliration for Disposal Works Tonstrurtio f rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at:....:!:...c/_-j�_ •�t/is =-W .S l ...... ..._....••---- ------------------------------------------- . ----------------------------- ---•-....... Location-Address or Lot No.n wrier Address �. � r - ..... ............. -............_.. Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.....-. .................................Expansion Attic ( ) Garbage Grinder ( ) `04 4 Other—T e of BuildingNo. of persons............................ Showers — Cafeteria a' Other fixtures .-•------------------•-•••-----• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity 5"t'gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area............._....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...............•-•---••••••----•--........................_.._..._........... ............_.............................................................. 0 Description of Soil........................................................................................................................................................................ W ....•••---••----------------•--•••--•-•----•----•---•-••--••-------•--------------------..........----••.......--=---•--••-•-••--....•-•--•----••--•---.....:_._....................--•-•-.......__..... UNature of Repairs or Alterations—/Answer when applicable..22t:.'_T ` .��_... ..`_.�_u..'-.��.F'/ 7.N�'fi_ .................................. ...............:.............................w ...................... ........_ ....__.._ ._....._........................._._.._.._................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of hh lth _ r. / Date Application Approved BY - •- +..................•-----------•--•-•----. q.(J-L`- ...-•------•--- -.... Date Application Disapproved for the following reasons:..........................................................................................................--- ......................................................•...--......------------•-•-------..........---•---.••••--._...--•---•---•••-------••--••-•--•......•••-•-••---•--•••--•--••-................._.... L�_�- /�� Date Permit No... =fK ' ------_ Issued........... I !f-`� ........................ Date THE COMMONWEALTH OF MASSACHUSETTS .�- -_- - BOARD OF HEALTH Tertifirate of Toutplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( � G .�-� by---------------------------- ---------- - -----•-•-••• nstaller-------- ----------•------•--------•-----------•---•--•--------------------- ------- ' I p at...............................................Ti •r+� =. r� S /�>�✓ �f- T.. .... . has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................rl -15..::'S.�............................... Inspector---------- -y ................................................... THE COMMONWEALTH OF MASSACHUSETTS _-------` BOARD 4F HEALTH. Khopouttl orku ion tr�ution [prmit Permission is hereby granted.........,= '`•.._C to Construct ( )/or Repair4-�an Individual Sewage Disposal System ' at No...... 'r- fe!----�-•---. dv i� i S / G��,/ �.- �=- , z- T ! = �' -'.'./ !:...... ............. •-•..................•-----•-----•---...............I.....••----. ----...._..... -- Street -, as shown on the application for Disposal Works Construction Permit No....`.....L...%.. Dated....._..�j.��......................... Board of Health ' .....DATE............ FORM 1255 A. M. SULKIN, INC., BOSTON .i TOWN OF BARNSTABLE yA LGC1�rION SEWAGE VILLAGF.Cc 1,,7 A4,, Ile, ASSESSOR'S MAP 6z LOT 2 j/ - 0-1 JU INSTALLER'S NAME & PHONE NOoo��o_ G 77, / SEPTIC TANK CAPACITY 5 C LKEACHING FACILITY:(type) (size) 0 NO. OF BEDROOMS o"" PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Jw O a, DATE PERMIT ISSUED: 14, V 9 DATE COMPLIANCE ISSUED: .VARIANCE GRANTED: Yes No , / 4 f \ j iv G� TOWN OF BARNSTABLE LOCATION 570 ( . n f'1 e-&S �pC. , SEWAGE # VILLAGE 4e= �y�JQ. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �] j (;� ( -L SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r.. oJ/ f r Y 5 X\