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Home My WebLink About45/47 CROSBY CIRCLE - Health ys/47 Crosby ' c A = 18$ — 06 3 C terville l 1 i Surma UPC 17534 No.21�53COR '�cr r.ASTINGS. MN Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r.- �; 47 Crosby Circle u� Property Address t David Curtis Owner Owner's Name information is ✓ '7 required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection �ri Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information v!9f on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path r� Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes OF 2. ❑ Conditionally Passes ,��.• �y MICHAEL '.CP 3. ❑ Needs Further Evaluation by the Local Approving Authority _o SEARS Tj * No.SI14430 4. ❑ Fails 5 IN III l 9-1-20 Inspector's Sigafture Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of`Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000.gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �v ,� Title 5 Official Inspection Form I', Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ <-,� 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. ' 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or.more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 47 Crosby Circle u Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip,Code Date of.Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or breakout or high static-water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y . ❑ N' ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced. ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. . a. System will pass unless Board of Health determines in accordance with 310 CMR - 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts . �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle V� Property Address David Curtis Owner Owner's Name information is Centerville required for every Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The s tic tank and SAS and the SAS is less than 100 feet but 50 feet or system has a septic more from a private water supply well**. P pP Y Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 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 El due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official- Inspection Form + I1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water,supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet } from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the'system is within 400 feet of a surface drinking water'supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11_of a public water supply well t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is Ma. 9-1-20 required for every Centerville page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® O Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2018- 88000 gal g ( y g (gp )) 2019- 104000gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: presentDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts. Title 5 Official Inspection Form �0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: _ F Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 2018 Was,system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology-Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2511 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for VoluntaryAssessments u- 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1511 Depth below grade: feet Material of construction: 2 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 1" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with 2 inite tees and outlet tee in place, center cover at grade with in and outlet covers at 15" under stone patio r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 47 Crosby Circle u— Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Dace Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal [],fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form i1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `............. <-,� 47 Crosby Circle u� Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is located under stone patio was unable to open used camera box is 16x16 with 1 outlet pipe t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �� Title 5 Official Inspection Form 1 �i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle V Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan):- Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 1.1. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 47 Crosby Circle V� Property Address David Curtis Owner Owner's Name information is E required for every Centerville Ma. 9-1-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit at 37"with cover at 18" below grade pit is clean and dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of.hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle V Property Address David Curtis Owner Owner's Name information is required for every Centerville Ma. 9-1-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 a Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmer is 47 Crosby Circle Property Address David Curtis Owner Owner's Name information is Centerville Ma. 9-1-20 required for every page. Citylrown State Zip Code D to of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 13 C Anc,�, o I q pa M- l3Qi I"1 d 33 OF fM rs//// ti- ICHAEL (P o SEARS o.SI14430 N �U/lllfIIIIIIItIt�A t5insp.doc.rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewa a Disposal System•Page 16 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address David Curtis Owner, Owner's Name information is required for every Centerville Ma. 9-1-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: . Back lot drops 20'+with no sign of ground water Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 I Commonwealth of Massachusetts �- Title 5 Official Inspection Form. Form -Not for Voluntary Assessments b dace Sewage Disposal System o .� Subsurface g p y rY !% 47 Crosby Circle L— Property Address David Curtis Owner Owner's Name information is Centerville Ma. 9-1-20 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 6vvde &44cA 0� S& ;to ND t5insp.doc-rev'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts �..0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for Y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information n forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name V`R" 189 Cammett Road Company Address Marstons Mills MA 02648 "df1 Citylrown State Zip Code 508-428-1779 SI 12855 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority lv� ()"I July 10, 2012 Job# 12-121 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of Ilse at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 UVd 31mlsoi /b T Commonwealth of Massachusetts = Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is . Centerville MA 02632 Jul 10, 2012 required for y every page. Cityfrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumpping at time of inspection, leachin gpit showed no evidence of surcharge or saturation. 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 Ipass 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 July 10, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Cityfrown 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 ❑. ® 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 El ® 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•11110 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 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Cityrrown 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ! 4 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 July 10, 2012 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® El 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Cityrrowti State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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.): t� 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Citylrown 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: None 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): l5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide- 1500 gal. 2" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for Y 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 30" Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees were intact and clear. 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for Y every page. Cityrrown 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•11/10 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 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is required for Centerville MA 02632 July 10, 2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 lt Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts EUNUftill Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit located under landscape area, was not excavated. Probing of stone and soils surrounding pit found no signs of saturation. 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-11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "f 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for y every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage dis° osal 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 r / , / / r r`;` ♦r♦/r,♦/♦r♦�♦�♦�♦�♦�♦ ♦�♦r♦�♦/tr♦rtrt�♦'♦/♦/♦ ♦/♦f♦/tl♦/ ♦ ♦ ♦ ♦ t ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ t ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ t ♦/t!♦/♦/t/♦/♦/♦/♦/♦/t/♦,♦,♦/♦r r41-11 rr/ ♦/♦/rrrr♦/t/♦rtrtrtr♦/♦/♦r♦r♦/tr t'trrrtrt/tit/♦�t/♦r♦ 13 , ♦ ♦ ♦ ♦ ♦ t ♦ ♦ t ♦ 29 t ♦ ♦ ♦ tr ♦ ♦ ♦ tt 26 t'♦'t't't`t't't't't't 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for y every 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: 20+ 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: Low points of adjacent properties with no surface water are considerably lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Crosby Circle Property Address Donald Patrick Owner Owner's Name information is Centerville MA 02632 Jul 10, 2012 required for Y every 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 3 TOW-4 OX BARNSTABLE LOCATION i Cr6s b` u.,r �E � ram, - MLLAGE ewterl u ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE N OY011 �- SEPTIC TANK CAPACITY 0 50C) geky LEACHING FACILITY:(type) 1 (size) 4011K`o NO.OF BEDROOMS 1I OWNER PERMIT DATE: Cr &n—&DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within I' 300 feet of leaching facility) Feet FURNISHED BY f r'!-f-• r'•�f • r f f f r f • • • • • f.r r r r f r f r f f r r r f.f r ♦`t`t ♦ t ♦ ♦ ♦ t t t t ♦ t t ♦ ♦ t t t t ♦ t t ♦ t t ♦ ♦ ♦ ♦ ♦ t F f F r f / f • f r • f f / f • / I • • • • • • • • f • r • f f • • �. \ t \ t t \ \ ♦ ♦ k_\ ♦ t t \ \ \ \ t t ♦ ♦ \ t ♦ ♦ t \ . f f f f / / f I f f:• f ! f r / • f • • f / f f 1 f / f�ftlk/♦/t, ♦ k ♦ ♦'\ t \ ♦ ♦ ♦ ♦ t ♦ ♦ ♦ ♦ \ \ t t t \ t ♦ t ♦ t \ ♦ t ♦ \ f • f f F f f f f J f':J f • f f f f f J f f f f f f f f J J J . . f' F F f F F F J f f f f I f • F' • f f F f F f F / / f f f f / f / I • f / f • I F f f / f / f f f f f I I f f f f F / / / / f f f f f • f f - f f f F f'f'f f f f f .. f f f / • f • f f f - t ♦ ♦ \ ♦ ♦ t t 4 t t 13 t ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ , ♦•♦f\f♦f♦f♦f♦f♦f\f♦f\ f F f f F f f F F F 2 9' 26 \JtF♦J♦Jt/♦Jt/tf♦ft/♦ w� DATE;�11 /1_4/00___ PROPERTY ADDRESS;47_ Crosby_,Cj��--___ ---reutervi..Ll.a,,lYlassT----- 02632 ------------------------ On the above date, I Inspected the septic system at the above address. This system conslsts of the following; 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. eased on my inspection, I certify the following conditions; 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time. SIGNATURE: ./ N a m e:_,��3.�1-i9S9Mt;.a.L. ------ Companyc Jeeeph_P ; Nacomber_b Son , Inc , Address :- Box_66______ __Centerville Ha_ 02632-0066 Phone;___ 508_77S_3978_______ THIS CERTIFICATION 001'S NOT CONSTITVTI'_ A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tinks•Cfsspools•LsachfIold$ Pumped 4 Instilled Town Sewer Connoctlons P.O, Box 6775.33J89rY1114, A 02632.0066 RECEIVED DEC 0 7 2000 TOWN OF BARNS7ABLE HEALTH DEPT. Ft s•.' COMMONWEALTH OF MASSACHUSETTS IV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292•6600 TRUDY COXE Secrvtaiy ARGEO PAUL CELLUCCI DAVM B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERT1FiCATION PropertyAddrsss:47 Crosby Circle Michael Pusateri Centerville as . 02632 Addr.eaoffO resr:T e a e Court Dieu of inspection: 1 1/14/0� McLean V.A. 22102 N am@ of ; i pwase print) O S e h P. Macomber J r. am a DEP approved system kupector pursuant to Section 16.340 of TM* 5(310 CMR 16.000) co,>,panyN,rne; Jose h P. Macomber & Son Inc. µa&NAddryss; ox 66 , Centerville, Ma. U632-0066 T*kK*.«»Nunba+ 7 7 5—3 3 J CERTIFICATION STATEMENT I cerdty 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-sits sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails tnspecrta's Signature: j, Dater The System Inspecto' shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin 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 %hail submit the report to the appropriate regional oMce of the Department oKnvironmercall PTotection. The original should be sent to Vw system owner and copies sent to the buys(, If applicable, and the approving authority. NOTES AND CONIMENTS revised 9/2/98 Page iorii `� Printed on Recycled Pope( r 1 r SU93URFACZ SEWAGE DLS►03JLL SYSTEM W3KCTION FORM PART A CfRTViCA,noN (oorsdnue41 PropoMAddreu: 47 Crosby Circle Centerville,Mass. OWTVar, Michael Pusateri Dorm of ~+°`ct—:1 1 /1 4/0 0 P03recnoN SUTAUAnYt ch—k /1, B, C, a P. A.9EEEiESI 1 have not found any Intormadon wNch IndlCatea that .ny of the Wun oor4ftl a dwribod In 310 CMR 14,303 ex.4L Any fa: v teria not svalu&tad us Indlcatad below, Co 411 DM: S, SYSTDA CONOMOkAUY PASSES: Ono w more system swnpononta N described in the 'Cor► %:I* al ►aaa' section Mod to bo replaced or ropalred. TAa sretam. cwr%plodon of the ropl000ment w ropalr, as approyed by the Soard of Health, wW paaa, tn4eots yoo., or not doterminod(Y, N, w NO). Doserlbe b"a of doterrr-nation In 4 Inatarwea, If 'not detemtlned', tuplaln why rwt. c3sY rho sopdc tank Is moral, twoaa the ownor w operatw hM provided the system Irtapeator whh o copy of a CorVVRuto Compdonce lottached)1"Godnp that the tank waa Inat"od wlthln twonty(201 Yta+o prior to ow date of VW wp.coc the aepdc tank, whether or not metal, la orocked, ouvewragy unaound, show# oubotandaJ tnWadon w eaTVvodon, a fallure Is ImrNnont, The ayatom will pass Inapeotion If the exlatinp sspde tank la replaced whh a coergx np septic tri approved by the Board of Health. $swap@ backup or breakout or high static water loyal observed In the dlstrUtIon box It due to broke+oe obev%ocud p or duo to a brokon, sorted or uneven d!&tr(bution box. The system wW pace Irtapeotion If (wfth approvaJ of V%4 Boaro c Healthl• broken pips(s) we replaced obawcdon It removed WsviWdon box It levelled w replaced �� • The syom i*gt.*ed pumphi r�mary titan-tour v"ardue t9 broVorn obevvotrd pipe(+), the 7YtR►*r+ wvSic.r rt InipocUon If(wlth app(ovd of the Board of Hoalth): broken pipe(&) are replaced ob&wcdon Is removed revised 9/2/98 of It t 1 y SUBSURFACE SEWAGE DLSPOSAL SYSTEM WSPECTION FORM � PART A CERTIFICATION (con*wod) Prcp✓tyAdbesa: 47 Crosby Circle Centerville,Mass. o..r•wr: Michael Pusateri ""coo": 1 1 /1 4/0 0 C. FiJRTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evalu►tion by the Board of Health In order to determine if tho system If fttAing tQ protect V'W publlc health, safety and the snvlronment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETVWINES W ACCORDANCE WITH 310 CIaR 16.303 I1Kb)THAT THE SYSTEW IS NOT PJNCnONWG IN A btANNEA WHJCK WtLL.P'ROjECT THP pUBUC HE LLTHAND LkFM AMD TH2 BOLBON1t1.9rL' d�Q Cesspool or prlvy is within 60 het of surface water Az Cesspool or privy Is within 60 lest of a bordering vegetated watiand or a salt marsh.. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLMR,IF A)Y)DET1:RMOU3 THAT THE SYSTEM tS pjNCTIONINO W A MAxNEA THAT PROTECTS THE PUBUC HEALTH AND SAFETY AN0 THE EWVl.RONJ 4WT: The system he► a septic tank and soil absorption system (SA31 and the SAS Is wltNn 100 feet of a wrface wet$r wppry or tributary to I svriace water ►upply. The system has a septic tank and soil absorption system and the SAS Is wit) a Zone I of a pubUc water wpply we1J. i The system he► a septic tank and aoll absorption system and the SAS Is within 60 loot of a private water wpprY weu. The system he► a septic tank and sail absorption system and the SAS I► less than 100 lest but 60 het or more horn ► prlvete water supply well. unisss a well water analysis for collform bacteria and volatile organic compounds lndJcata► put vw well Is free from pollution from that facility and the presence of smmoNa Nvogen and Nvste Nvogen I► equv to or less then 5 ppm. Method used to determine dl►tance_ A (approsj tlon not vaUd).• )I OTHER AW revised 9/2/98 Pa{e3or11 r SUBSURFACE SEWAGE DISPORT A SYSTEM WSPf-:CTION FORM PA .S CERTIFICATION Icorrekeu-6d) Pope Adds'"': 47 Crosby Circle Centerville,Mass. Owner: Michael Pusateri Dame 01 vapecton• 1 1 /1 4/0 0 0. SYSTEM FAILS: ns exist as You must Indicate either 'Yes' or 'No' to each of the following: I nova d•termined the, one ormore The the following Healthallure conbedcontact d to deterlrnl s i what will to rt•ct be n•ceeaary co the f"1 dsterminatlon Is identified below. Yes No oornponertt•doeto en overlwded orvlegpd Backup BASor�cNsPod• j'-` - ` p o+eewaq•Irno hclWsy-ot•�'fe�+^t acku to the surface of the ground or surface water$due to an overloaded Or dogged $AS or Discharge or pondlnq of effluent cesspool, vel In th dlstribq n box above outlet Invert due to on overloaded or clogged SAS or cesspool. Static liquid le Liquid depth Inless than 6' below Invert or available volume Is less than 112 day flow. Required pumping more than 4 dmes In the last year No due to clogged or obstructed plpe(e) Number of times pumped Any portion of the Soll Absorption System, cesspool or privy Is below the high groundwater elevation. ce water supply or tributary to a wrfac•water wpWy' Any portion of I cesspool or privy Is within 100 fast of a surfs Any portion of I cesspool or privy Is•wi%Nn a Zone I of a public well. Any portion of a cesspool or privy Is within 60 fast of a private water supply well. Any portion of s cesspool or privy Is less•then 100 feet but greater than 60 feet from a privet• water wpph weU with cepts acceptable water quality analysis. nalysis.O.compounds,itthe well as been analyzed Nu 9�`o be accts Nuogsn ach copy of weu water analr► s ' -collform bacteria, volst 9 E_ LARGE SYSTEM FAILS: You must Indicate either 'Yes- or 'No' large eachof the I n to the criteria above:f ollowin The following elite fie apply i q Ya nlflcant tNeat t .� The system $Irv@ a f thielti with a design flow of cave.one ,000 gpd the eater fLarollowingcondlt gs to exist: and system Is • sJ9 health and safety andYes N9/ (/ the system Is within 400 fast of a surface drinking water supply / er -te�eur/eo+� 4'M'eser+u►1�Y"" the system la-w11� 200 leotof+M ►t Y the system Is located In a Ntrogen eensltive area(Interim Wellhead Protection Area IWPA) or a mapped Zo+�s 11 of e Wolof supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Pleas•consult tt+e IoGal r oMce of the oepartment for further Infognatlon. Pegg 4 of It revised 9/2/98 ,1 t T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, � PART/ ' CHECKLIST PT.q.-TyAddr-4:47 Crosby Circle Centerville,Mass. own..: Michael Pusateri o.te of 4"pecdon1 1 /1 4/0 0 Chock 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. Norw of the systsmcomoo&ianu 1►aucbwn h"A w ,aoel q.e■ol A rates during that period. Large volumes of water have not bean Intrtiduosd Into the system rocondy or as pan of w► 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 *swags backup, The system does not receive non•sonliary or Industrial waste flow. _ The ske was Inspected for signs of breakout. _ All system componsnis..lsicluding the Solt Absorption Sy*tom, have boon located on the site. _ The septic tank manholes wero uncovered, opened, and the Interior of the septic tank wee Inspected for cor4tion of Der or isss, material of construction, d)menslons, depth of AQuid, depth of alvdgo, depth of scum. The size and location of the Soil Absorption System on the alto has been determined based on:- _ Exl►ting Information, For example, Plan at B.O.H. _ Ostermined In the field (If any of the failure criteria related to Part C le at Issue, approximation of distance Is vnacceptao (16.702(3)(b)) _ The facility ownu clWarani Wformarloo on rho ls�:^•,l^ ^ia SubSurl*ce Disposal Systems, revised 9/2/98 Page 5ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION Proge.tyAadr.aa: 47 Crosby Circle Centerville,Mass . own«: Michael Pusateri D-- m `P-0—: 1 1 /1 4/0 0 FLOW CONOMONS RES*eiT1AL: Design flow:__L�4—9-P-d.lbedr M. nn Number of bedrooms (design): Q Number of bedrooms(sctual):'4 Total DESIGN flow Number of current resldents Garbage grinder(yes or no): NS Laundry (separate system) I es or io If yes, sspsj+u�+pec0on.requlrsd —. Laundry system Inspected ye or no) Seasonal use (yes or no): 1 998-234-154 000 allons=641 . 1 0 GPD Water meter roodings,If eve able (lost two year's usage(gpd): � ' a ions=421 . 92=GPD Sump Pump (yes or no): ' j000 g Last date of occupancy: 6-Months2000-1 4, 000 gallons= 76. 51 =GPD r,OMssERCU►UtHDVSTRIAL: Sprinkler system is present Type of establishment: AA Design now: d ( Based on 16.203) Basis of design flow Grosse trap present: (yes or no) Industriol Waste Holding Tank present: (yes or no).J2 r Non•&&r"ary waste discharged to the Title 6 system: as or no) Water motor readings, If available: Lost date of occupancy: r OTHER: (Describe) � Last date of occupancy: GENERAL INFORMATION PVMPiNO RECORDS and source of Information: No System pumped as part of Inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: ./ TY P£0 Y STE)41 Septic tank/distribution box/soil sbsorptlon system �4,,, Single cesspool AJA Overflow cesspool Aln Privy —775 Shared system(yes or no) (If yes. attach previous Inspection records,1f any) I/A Technology sic. Ansch copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other I�►' /,� A OX17dATE AGE of all components, date InetsGed,ilf known)-end soul"olJn/orrnadon: '•-+ tl �- /lrIlt�� Sewage odors detected when•arrlving at the sits: (yes or no) revised 9/2/98 Patt6of11 SUBSURFACE SEWAGE DISPOSACSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(con V-d) P„p.,tyAddre„: 47 Crosby Circle Centerville,Mass. owner: Michael Pusateri D—11+lr�:1 1 /1 4/0 0 BUILDING SEWER: (Locate on site plan) f Depth below grade: _ Material of Conswction: cast Iron-0 PVCrk other (explain) IVA Distance from privet• water supply well or suction line�_ Diameter ! Comments: (condition of Joints, venting, evidence of 1t+akage,-su.) Joint st SEPTIC TANK: Jl (locate on she plan) t Depth below grader Material of construction: ncreteLL—talA�FlberglasvGj4 Polyethylene�L�other(expleln) If tank Is fnetal, list age kff is.age.conflrmed by Cerdflcaato of Compllanc• (Yes/No) Dimensions: Sludge depth: =1� _. Distance from top of a dg•to bottom of outlet tee ortr@M1/_ Scum tNckness . Distance from top of scum to top of outlet tee or bsMe:2'r _L ,�,�- Distance from bottom of scum to bo of oude to of batfls:2"i,�-�> Mow dimensions were determined: Comments: irecommendation for pumping, condition of Inlet and outlet Nee or-baffles, depth of liquid level In relation to outlet invert, etructvrefir+tegrity. evidence of leakage• etc.) . Je tic t Garn1 Pi- n piace.Ll Ujd_depth' oRFasE TTiAP: shows no evidence of leakage. ly sound and (locate on site plan) Depth below grade: AM Material of construction: concreteijyrttetal/j&bsrglsssAl A Polyethylene other(explain) AM Dimensions: Scum thickness: Distance from top of scum to top of oudst its or baffle:A&. '� Distance horn bottom of scum to bottom of outlet tee or,baMs:" Date of last pumping: Comments: ogrtty. trecommendation for pumping, condition of Inlet and outlet test+ or baffles, depth of liquid level In relation to oudet Invert, etructureJ nt evidence of leakage, etc.) rease trap revised 9/2/98 Paee7of 11 SVRSURIACZ SEWAGE 013POSAL SYSTEM WSPECTION FORM PAAT C SYSTEM WFORWATION (eorrtlrti P,,,„TMAte9": 47 Crosby Circle Centerville,Mass.' 0-WrW: Michael Pusateri 0.'0 °' tr"v+c60n:1 1 /1 4/0 0 TIOFfT OA MOlDWO TANX412kWank must be pumped prior to, or at Um• of, In•p•cdon) (locate on site plan) 0•pth below grade:eA Melerfd of coneVucVon:�J(�oncreteQm•taJ�l�Flb•rglaa ►dyethylant�f�othar(oxp!•ln) .—... -- Olmenalon►: jgA Capaclry; ! gallon► 09►ign Row: g►Ilons!day Alarm present Alarm level: Alarm In working order,Y$$!�1(t No�iQ Oats of p(•vtoVr pVmPIAj1 IA Icondfdon Of IrJ•►teoCOMMOAW . condJtlon of alarm and float $witch•$, etc.) r oldin� t any ��—,. --P WTRI8Vn0N SOX: uoc•I• on Nte plan) Depth of liquid level above oVd•► InVIM: Comm1 level — Ina•,a I•v•l and olstrlbutlon la •qu.J, •vld•ne.e of adld$carryover, wid•ne$ of leakage Into or out of ►oa, •te.l Distr ' 1 ence 0 or the-box. PVMP C14ALA5M:, notate on site plan) ►ump► In working order:(Yes or No) �r Alarm► In w9AIn9 order (Yes or No), Comment►: Inole condloon of pump chamber, condlVon of pump$ and oppurionance$, etc. --------------------- ump c hill of 11 revised 9/2/96 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (condrawd) PrWerty Addre"47 Crosby Circle Centerville,Mass. Dom: Michael Pusateri Data of Inspeati«t: 1 1 /1 4/0 0 SOIL ASSORPTION SYSTEM(SAS):,4 (locate on site plan, If possible:excavation not required,location may be approximated by nonantrusive methods) If not located, explain: Typo: leaching pits, number:_, loathing chambers, number: Isoching galleries, number: losching trenches, number, length: IeacNng fields, number, dlrnn one: overflow cesspool, numbor Alternative system: s^7 Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (iocate on site plan) Number and configuration: Depth top of liquid to INot Invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indicedon of groundwater: Inflow (cesspool must be pumped as part of Inspection) Commonu: (note condition of soil, signs of hydraulic failure, level of ponding,condition of,vogetation, etc.) PRM: ve- (locsto on site plan) Materials of construction: �� Din►enalona: /L✓/ Depth of solids: 4)4 Commonu: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vogetedon;etc.) revised 9/2/98 reer9orII I 3UI3URPACI IEWA01 DISPOSAL VYVTVA LNSKCT'ON FOPM PART C ' SYITDA WFOpmAT10N (Gar"kWod) P,Qq.eTyA6&0"A7 Crosby Circle Centerville,Mass. oWTW: Michael Pusateri C>.0 91 1 1 /1 4/0 0 SKETCH Of SEWAGE DISPOSAL.SYSTEM: InclVdf too to at Leah two pormononl reference landmuks or bonchm iks locoto all well► wlthln loo, (locsto where publlo water supplY comes Into housol No. Per Sys 'O and s con S/ Pro t Dau I y7 6 shy revised 9/2/98 Nit loorll ,t ti SU93UAFACE SEWAGE=1`95AL SYSTDA W3/ECn0N FORL' + _J PART C SYSTDA 1lJFORI.I MN (condrx ) hoq�rtyAddr�++; 47 Crosby Circle Centerville,Mass. own«: Michael Pusateri Dou of v"°"do"`1 1 /1 4/0 0 NRC$ Report name $ou Type_ Typical depth to proundw#tsr VS05 Oita weboIN visited OoiorvlDon Well& checked Orovndwsiot dt'pth: Shallow Moderate 044P SITE EXAM Slope Svrloco water Chock Collar Shallow wells Ett,malld Depth to Orovndw#trrr LLr Feet hglrq indicate oil the methods vssd to determint, High Groundwater EJ*vofJon: _ Obtained hem Dssipn piano on record �ba ervad Sit. IAbvtdn9 prop-rty, bafervadon hole, baaemaot wmp •to.) O�tt�min�d from local condltJonrf Chocked with local Solid of health Chocked FEMA Maps Zhocked pvmpinp records -,—/Checked local kscavktorr, Inrtkll.n Vied VSOS Olt& Ocrcriot how yov •atabAthad the Mlph Grtwndwater Veye on. 1MRB be completedl J.P.Macomber & Son Inc installed existing septic system. 1 /14/98 Permit # 97-686 No water encounted at 141 Use; Water Contours Map. Gahrety & Miller Model 12/16/94 revised 9/2/98, h�rllofll COD: .. T'•^nt'T'rtr.etrtr..'nmrsl+r..Trrr.r.:•.Te-*tram:srrr..rn trrs4.s*ra-r.7er.trn Tn^rrr-T—r-- -. -_...` rT Barnstable 'I'UHN OF BOARD OF HEALTH SUIISURFACE SF.HA(;E DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I.••.-••: r••.•... -�. f.^.�T:ISf1.1')(.'t�ITTnITf ITfRT1'�-•.'I TRR11m1Yr-TRTR4TRRTA.Hl.'P."Ifr7 lfRtR7RT�ASI!"+TRRRr•.�nPT•T•�. �..^ -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 47 Crosby Circle Centerville,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Michael Pusateri PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & SonKYnc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City Stat• LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 q CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that tile information reported is true , accurate , and omplete as of the time ofeinspection . The inspection was performed and any recommendations 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 ; 6 System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe. environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILEll* aThe inspection which I have conlcted has found that the system fails to protect the j)ublic health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . •e t - Inspector Signatur ill r Date �� ynecopy of this certification must be provided to the OWNER, the BUYER re applicable ) and the I30ARD OF HEALTi(. * If the inspection FAILED, the owner or"'operator shall upgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 . 305 , partd .doc TOWN OF BARNSTABLE _ LOCATION J/ 7 C K[, S h V . C C I l SEWAGE # y7 r «,I•AGE C e m Im V/llOp ASSESSOR'S MAP & LOT �� INSTALLER'S NAME&PHONE NO. A C 0 A � 8� SEPTIC TANK CAPACITY `.-0 D Al e Ul LEACHING FACILITY: (type) /e"7 (size) / 0 OO NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: C/ 7 COMPLIANCE DATE: 1 L/ g Separation,Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by L fl 9 ell\ LtiCATION �- , SEWAGE PERMIT NO. V ► L A G E m�Pla3 INSTA LLER'S NAME i AD.DRESS 7 O'19zezee-,ZA2 £ 0 U I L 0 E R OR OWNER A DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� i i k /3� \ ,.3 -, \ � / \e � / /��' \�� `1 .a ' ,I 1 i �,., '; .............. THE COMMONWEALTH OF MASSACHUSETTS SOAR® . F V T ........OF....... .............................. AVVIiration for Uhipaii al Vurk,5 Toni Arurtinn Urrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System A t ...y LX ......... 4 -------------------------•---•---•-•..... •-- ion-Address or Lot No.... ................... .... r Address w � _._ .� � Installer Address T e of Building Size Lot............................Sq. feet V Dwelling No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( } a' Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------- ------------- -- ---------------- O Description of Soil......ZC4. ..?.... " V -----------------------------------•-----------------------------------------------------•-----------------------------•----------------------------------------------------•-------•----------•---- W --------------- --------------------------------------------------------------------------------------------- - -------------------- UNature of Repairs rations—Answer when applicable.___ .:__ !" 4 ......... ...... ................................... -------- ---- ..........>....................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI i U 5 of the State Sanitary Code—The undersigned further agre not to place the system in operation until a Certificate of Complian has b n issued b thglboar of health. Sig s.- /r C Application Approved By---; ------------------------------------------------------------------ l -------- Date Application Disapproved r t e following reasons--------------------------------------------------------•-----------------------•-------------------------•----- --------------- ------------------------------------- ---•---------------------------- ------------- ----------------------------------------- •..................................................... ,Date PermitNo......................................................... Issued----...--------------------- Date No..r..�.�..` '.j.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE ; ' /T / -..-:-.......OF....... ....:.......................... Applirtt#iun for Diupuuttl Worko Tonstrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: I -•1!`��.. -� '� k -de"641 ,1� of------- to -•-•---•--------------------------•----- ----------------------------------------- �} Location-Address or Lot No. C � .....: ..... -------•--_............................... ..........-•...................................................................................... ( ner Address W !. .:.. --.-S.�----:7 ►-a Installer Address T e of Building/ Size Lot............................Sq. feet U Dwelling No. of Bedrooms................................::..........Expansion Attic ( ) Garbage Grinder ( ) Other—T e of BuildingNo. of persons............................ Showers — Cafeteria Q1 Other fixtures ------------_-_------------- . ... W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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...................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... O Description of Soil...... x U ------------------•---•--•-----------......---......----•-----•--•----------........----•-•-----.........------------------------------•--•----•------------------)------------------...-••------------- W -----•••••-•.................................. ................. •••--••••••-............................-- a 1 U Nature of Repairs rations—Answer when applicable...._!._".., f` ''..f�tl ---------•............. .. ------------- �------------------------------------.--------.--------------------•-----------------------------•--------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complian has be. n issued b th boar -of health. ll y+ Signei_• - •-- = _.J'_ ---• --- , ..-•--• j/""� l!. ( d fit' atgd Application Approved BY----- --- ....-e'` -------•---....---•----------------•-•---•-- f f= Date y Application Disapproved/t following reasons:---••----...---•-----••-......-••---•----•-•-----•--------••-••-••--•------•------------•-•-•-•-......•------- r' ------------•---- -------------------------- ------------------------------------------ Date PermitNo-----------------------------------------------•-----•-- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS _,,,,•�» BOARD' OF' HEA . T ,_ , a -.......OF........ . ................ . ... ...... ............................... C�rr�if irtt#�e of fau�t�littnrr j(SJS T RTIFY, .:hat the I ivldual Se ge Disposal System constructed ( ) or Repaired ------------------------------------------------------------------- at. _ .. ._.._..._ -------- .....-•----- -------- - ------- - ---- --------------------- has been installed in accorde with the provisions of TI`" F��jroThe States Sanitary Code a�c�g� 'bed in the application for Disposal Works Construction Permit No.___�-__•--_--Ia_--_-----_.-_•___-___- dated....��_./_i__/_-..-................. THE ISSU NC OF TIIS CERTIFICATE SHALT. NOT BE CONSTRl1E 'AS A GUARANTEE THAT THE SYSTEM WI //F NC' JON SATISFACTORY. DATE....:. 1.... ... Inspector...... ................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD Or HEALTFi a, / r/ -........OF..... -- No... ....... FEE....0144x ...... 14uP0.04 Ivor u %pnu Tun r i Permission is hereby granted at ...f.� �'' .. :..._..x'�r '" ...------. to Constru t ) r Rye it ( ns Indi;�i ual Se e isposal System ll ,`. Street / ! as shown on the applicatio for Disposal V�orks Construction Permit No..f,-__... A~ w `-". ................................ ................ •-------- oard f Health DATE -----•----•---•--•------------------------------- r {r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS