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Home My WebLink About0194 DONEGAL CIRCLE - Health 194 Donegal Circle Centerville A= 169- 037 i i ;k No. 42101/3 ORA 1000 (0 ® 6 0 _ _ _ . Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=11121 Logged 6 _�Jl-� Parcel Detail Wednesday, May 9 201.2 ��i� Parcel Lookup Parcel Info Parcel ID 169-037 Developer LOT 20 Lo Locati 194 DONEGAL CIRCLE Pri Frontage 146 Sec Road LIETRIM CIRCLE I Sec Frontage 106 village CENTERVILLE I Fire District C-O-MM Town sewer exists at this address No I Road Index 0449 Asbuilt Septic Scan: Interactive 169037_1 Map Owner Info owner DILULLO, DANIEL J & MILDRED Co-owner %HOBBS, JANET K Stre tl PO BO�494 Street2 City CENTERVILLE I State MA I Zip 02632 Country Land Info Acres 0.43 use Single Fam MDL-01 I Zoning RC Nghbd 0105 Topography Level I Road Paved Utilities Public Water,Gas,Septic I Location Construction Info Building 1 of 1 Year 1970 Roof Gable/Hip I Ext Wood Shingle Built I Struct Wall DILO Living 1413 I Roof Asph/F GIs/Cmp I AC Central Area Cover Type 1 Style Ranch Int Dry wall I Bed 3 Bedrooms I 16 '16 '42 Wall Rooms GAR 1616 BAS 1 w Model Residential I Int Hardwood I Bath 1 Full + 1 H 20 Floor Rooms 16 BMT 2 16 Grade Average I Type Hot Air I Rooms Total 5 Rooms I 11 23 Stories 1 Story I Heat Gas I Found- Typical Fuel ation Gross 3010 Area - Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=11121 5/9/2012 Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=11121 1 II Issue Date I Purpose Permit# Amount Insp Date I Comments II Visit History Date Who Purpose 01/28/2011 00:00:00 Michele Arigo In Office Review 01/20/2011 00:00:00 Michele Arigo In Office Review 07/09/2008 00:00:00 Paul Talbot Cyclical Inspection 06/08/2007 00:00:00 Sheila Fowler In Office Review 05/04/2007 00:00:00 Kathy Perry In Office Review 12/20/1999 00:00:00 Donna Dacey Meas/Listed-Interior Access - Sales History Line Sale Date Owner Book/Page Sale Price 1 10/30/2002 DILULLO, DANIEL J&MILDRED 15827/019 $1 2 10/17/1974 DILULLO, DANIEL J &MILDRED 2109/298 $0 3 04/04/2012 HOBBS,JANET K 26219/254 $220,000 4 04/04/2012 DILULLO, MILDRED 26219/251 $0 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2012 $103,900 $33,300 $2,000 $108,000 $247,200 2 2011 $134,900 $3,100 $0 $108,000 $246,000 3 2010 $134,800 $3,100 $0 $108,000 $245,900 4 2009 $132,500 $2,600 $0 $144,900 $280,000 5 2008 $160,400 $2,600 $0 $151,000 $314,000 7 2007 $159,600 $2,600 $0 $151,000 $313,200 8 2006 $142,300 $2,600 $0 $155,200 $300,100 9 2005 $131,900 $2,500 $0 $140,900 $275,300 10 2004 $107,200 $2,500 $0 $105,700 $215,400 11 ' 2003 $96,400 $2,500 $0 $46,900 $145,800 12 2002 $96,400 $2,500 $0 $46,900 $145,800 13 2001 $96,400 $2,500 $0 $46,900 $145,800 14 2000 $65,000 $2,200 $0 $32,300 $99,500 15 1999 $65,000 $2,200 $0 $32,300 $99,500 16 1998 $65,000 $2,200 $0 $32,300 $99,500 17 1997 $71,100 $0 $0 $28,700 $99,800 18 1996 $71,100 $0 $0 $28,700 $99,800 19 1995 $71,100 $0 $0 $28,700 $99,800 20 1994 $65,100 $0 $0 $29,100 $94,200 21 1993 $65,100 $0 $0 $29,100 $94,200 22 1992 $74,200 $0 $0 $32,300 $106,500 23 1991 $80,300 $0 $0 $50,300 $130,600 24 1990 $80,300 $0 $0 $50,300 $130,600 25 1989 $80,300 $0 $0 $50,300 $130,600 26 1988 $60,600 $0 $0 $19,700 $80,300 27 1987 $60,600 $0 $0 $19,700 $80,300 28 1 1986 1 $60,600 $0 $0 $19,7001 $80,30011 l http://issg12/intranet/propdata/ParcelDetail.aspx?ID=11121 5/9/2012 Parcel Detail http://issgl2/intranet/propdata/ParceiDetaii.aspx?ID=11121 f) Photos Orr is'+� f, 1 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=11121 5/9/2012 1 J • <LCommonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal Sy tern Form -Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 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 forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. D Iw^ B & B Excavation, Inc. r� Company Name 14 Teaberry Lane AUG- G 6 RECO I Company Address J U Solo Forestdale MA Plf02644 City/Town State 508-477-0653 S14595 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 inspectiorEffhe.Rspection was performed based on my training and experience in the proper function and maintena ee ogn site sewage disposal systems. I am a DEP approved system inspector pursuant to Sectioml5.30 of Title 5(310 CMR 15.000). The system: G--, o -n fv ® Passes ElConditionally Passes ❑ Fails o ❑ Needs Further Evaluation by the Local Approving Authority w a3 C-r' rn 000 8/24/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. tsins•osio 6 Title 5 Official Inspection Form:Subsurface Sewage Dispo al Syste/Igbel of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Cityrrown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I " Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 141 Lietrim Circle Property Address Steve & Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ... ..... . _.. ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. CityrTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 141 Lietrim Circle Property Address Steve&Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons i 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good condition -no sign of leakage Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 5.2"X 62"X 8'6" Sludge depth: no sludge t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection spetic tank appears to be structurally sound -tees present- no sign of leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 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 141 Lietrim Circle M Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At time of inspection d-box appears to be in good condition -no sign of solids carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 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 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 34'X 11'X 1' ❑ 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.): At time of inspection leaching appears to be in good condition - no sign of hydraulic failure , ponding or damp soils 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 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 ^M 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. City/Town 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 �V O s t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 141 Lietrim Circle M Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8124/10 page. Cityrrown 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: > 12'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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r, Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Lietrim Circle Property Address Steve &Joanna Ross Owner Owner's Name information is required for every Centerville MA 02632 8/24/10 page. Citylrown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - l � � POWTW rty Add Nv \ 0 Owners Name information is required for l_ 1 6 / �� o.�J3 z every page. Cityfrown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. � Important When filling out A. General Information forms on the oompuW'use 1. Inspector. / to m the tab key to 1 _ move your '�V.✓�1-�, cursor-do not use the return 4 of nspect key. ! 11:�C D Company Name (�(�' Company rew City[rown 2, state Zip Code G o� — c7-1 TedOxm 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 CHAR 15.000).The system: dpa'sses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1 Inspector's re o 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 gr 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. tsinsp.doc•08M Title 5 OfWaat Inspection Form:Subsurtece Sewaoe Disposal system-Pap 1 of 15 r� a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Owner Owner's Name required fo C2 y�ka 1�e A OZJo32 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form.Inspection forms may not be altered In any way. important When filling out A. General Information forms on the ' computer,use 1. Inspector �✓ I only ttre tab key to move your cursor-do not of use the return key. Company Name a► . Company ress. AM 026 � ^e�0 Cily/Town State Zip Code —C C7� TeWphom 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 Lgd7sate. ( �o Inspector's re 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. t5insp.doc•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pap 1 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1'4\ (_ eRlm COC Prgrty Add Owner owners Name lnfaffna*m Is every page. CIt frc n State Zip Code Date of Inspection B. Certification (cunt.) \Expt onditionally Passes(cont.): stribution box is leveled or replaced ❑ The system requ pumping more than 4 times a year due to broken or obstructed (s).The system will pass in on if(with approval of the Board of Health): ❑ broken pipe(s re replaced ❑ obstruction is remo ND Explain: C) Further Evaluation Is Required by the Boa of ealth: ❑ Conditions exist which require further evaluatio the Board of Health in order to determine if the system is failing to protect public health, fety the environment. 1. System will pass unless Board of H alth date es In accordance with 310 CMR 15.303(1)(b)that the system Is not f ctioning In a nner which will protect public health, safety and the environment: ❑ Cesspool or privy is wit n 50 feet of a surface water ❑ Cesspool or privy' within 50 feet of a bordering vegetat wetland or a salt marsh 2. System will fall u an the Board of Health(and Public Water upplier,if any) determines that th system is functioning In a manner that protec the public health, safety and envi ment: ❑ The s tem has a septic tank and soil absorption system(SAS)an he SAS is within 100 of a surface water supply or tributary to a surface water supp . ❑ Th system has a septic tank and SAS and the SAS is within a Zone 1 a public water s pply. ❑ e system has a septic tank and SAS and the SAS is within 50 feet of a p ate water supply well. Mnsp.doc•08ft Title 5 OlAdal Inspection Form:Subsurface Sewape Disposal System•Pape 3 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V-mi ern Property Address AALQ Owner 0 e s N n e Wifaffnadon is mqWred W C9z-VIMLI-A� , AAN o7632, oL4 (do I every page- Cityfrown State Zip Code Date of Insped idn B. Certification (cont.) C) Further Evaluation Is Required by the Board of Health(cont.): ❑ system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or mo a private water supply well"*. Method determine distance: '*This system passes if well water analysis,performed at a DEP rtifled laboratory,for coliform bacteria indicates absent an a presence of ammonia nitroge d nitrate nitrogen is equal to or less than 5 ppm, provided that ther failure criteria are t' red.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 cogged SAS or cesspool ❑ Ed Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cogged 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 ❑ 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. t5insp•doc 0a/06 Title 5 OfBdal Ins pection Forth:Subsurface Sewape Disposal System•Pape 4 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments PrQDerty Address formaom is e - )A _`�'� - Ng, low State Mp Code Date of Inspection B. Certification (cons) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ [� Any portion of a cesspool or privy Is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑- Any portion of a-cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes H the well water analysis, performed at a DEP certified laboratory,for fecal collform 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. ❑ G( The system fLiL2. 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 a systems,you must indicate either"yes'or"no'to each of the following, in addition to the question Section D. Yes No ❑ ❑ the stem is within 400 feet of a surface ing water supply ❑ Cl the system i ithin 200 feet 'butary to a surface drinking water supply ❑ ❑ the system is locat a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) map Zone II of a public water supply well If you have answered"yes't y question in Secti the system is considered a significant threat, or answered"yes'in S ' n D above the large system ha iled.The owner or operator of any large system considered ignificant threat under Section E or fail nder Section D shall upgrade the system in a ance with 310 CMR 15.304.The system owner s Id contact the appropriate regional o of the Department. I t51n doc•08I06 aP• Title 5 011ldal Inspection Form:Subsurface Sewaps Disposal System•Pape 5 d 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tw � P Address owner a Name information is A /� _�1 required for �(-�-1� �- _/. �--_k every page. City/Town SW87 Zip Code Date of In on 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? ❑ 0❑ Were as built plans of the system obtained and examined?(if they were not 1 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? [J ❑ Were all system components,excluding the SAS, located on site? NJ ❑ 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 Soll 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)1 t5insp•doo•08M Title 5 Official Ins pection form:subsurface Sewage Disposal System•Papa 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner s Wsl6m7 V Y v ink"nadonIs C Q A► „ ��A „ ,t� �26.3Z o- required for XS! \ V'C. /y�sT every page. CKYRown State ZIP Code Date of Iropedon D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): — Number of current residents: 1- 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)): NO Sump pump? ❑ Yes d No Last date of occupancy: Me CommercialAndustrial Flow Conditions: Type o blishment: Design flow(based o 10 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/pe s/sgA.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to th e 5 system? ❑ Yes ❑ No Water meter readings,' lable: Last date of pancy/use: Date Other( scribe): Mnap.doc-08M Tito 5 Official Inspection Form:Subsurface Sewape D oposel Systern-Paps 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ram-_,. L � ,r, �I Properly Address owner s Na �i ,is O�6 3 7- (411CX10-7 every page, cityrrow State Zip Code Date of Inspedw D. System Information (cont.) General Information Pumping Records: Source of information: TIP-( Was system pumped as part of the inspection? Yes Mj No If yes,volume pumped: gallons- How was quantity pumped determined? Reason for pumping: &PeC V' ey,veS�, Type of System: U [�] Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: y ��2 mj AC) CAS1 Uil_ ± Were sewage odors detected when arriving at the site? ❑ Yes [/ No t5insp.doc•08M Title 5 olridal Inspection Forth:Subsurface Sewape Disposal System•Pepe 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments YLAA Property Address DNIAA >� Owner shame rnforifirwom is equ OZb Z — —c--�I cif`L9- every page. City/rown State Zip Code Date TY Inspeacin D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: IL 1 Material of construction: [`cast iron d40 PVC ❑other(explain): Distance from private water supply P pply well or suction line: Comments(on condition of joints,venting,evidence of leaka1g_e,etc.): n Septic Tank(locate on site plan): Depth below grade: �^y 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: l 00 C,g(2_ ( l Sludge depth: Z tr Distance from top of sludge to bottom of outlet tee or baffle 3 `rt N Scum thickness r� cr Distance from top of scum to top of outlet tee or baffle S_ Distance from bottom of scum to bottom of outlet tee or baffle - I How were dimensions determined? !I-C)b rCJ t5in doc•OBV06 sD Title 5 gIMdM Inspection Form:Subsurface Sewape Disposal System•Paps 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V-tA tAN--A Nt C')[)n Property Address owrw Owner's NameInforrimmon is required for I 1 every page. Ci frown State Zip Code Date of II Lnspection! �� D. System Information (cons) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, vidence of leakage,etc.): o06 ( e v r 2 0 CvrnSiSke�N+ vSe. I Grease Trap(locate on site plan): Depth below grade: feet Mat of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene y ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet or baffle Distance from bottom of scum to bottom of outlet or baffl Date of last pumping: Date Comments(on pumping recommendations, inle nd outlet tee affle condition, structural integrity, liquid levels as related to outlet invert, evide of leakage, etc.): Tight or Holding Tank nk must be pumped at time of inspection) (locate on site plan). Depth below grad Material of cons ruction: ❑concrete ❑metal ❑fiberglass ❑polyethylene y ❑other(explain): t5insp'doc•08W Title 5 Official ins pection Form:SuDaurface Sswape Deposal System•Paps 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ProPeny Address Owner oa res� r e9 e kYWna*m is required 1br s Qw c M ()2&3 z 3 C:z every page. Citylrown state Zip Code Date of Inspection D. System Information (cont) Ti t or Holding Tank(cont.) Dimensi Capacity: gallons Design Flow: gallons per day Alarm present:_ ❑ Yes ❑ Alarm level: Ala ' working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm an oat switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): � rc 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.): mod S Ic-siAl ip2 G n=6 �0 n uj , r\ �)_ eo k c c Pump Chamber(locate on site plan): Pumps I ang order ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5insp.doc•0&06 7Ne 5 ORidw Inspection Form:Subsurfooe Sewa ge Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _1 LA t L L*'ef^M Cir Property Address ,p _CV,-AA/r) Owner OMWs ame irtforrrtatlon Is (�.h�\,12_, Z required for _ (� ®t+erY Pam• owrl Sta pZf i;ode " Dabe o Inspection D. System information (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: leaching pits number leaching chambers number: , ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): C U ` cwec'� 6e�.v�� some . A.6 sl�� o �_-)\ McY\S cons l 1' 31-C x ` r t5insp.doc•OOM THIS 5 OMcisl Inspecdon Form:Subsurboe Sewepe 01eposel System-Pepe 12 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address owner ow"rsNan% Wdbmufflonis cZrecpjkWfbrl(1i4e�1V� � Z b 110-7 every me. Gty/rown State Zip Code Date of Inspecdon D. System Information (cont.) Coss Is(cesspool must be pumped as part of inspection)(locate on site plan): Number a configuration Depth—top of uid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow X�Ig, ❑ No Comments(note condition of soil,signs of by ulic failure,levon of vegetation, etc.): Privy(locate on/P'an, Materials of con Dimensions Depth of solids Comments(notere, level of ponding,condition 6-1-vegetation, etc.): t5insp.Qoc•08W Title 5 Oftial Inspection Form:Subsurface Sewage Deposal System.Paps 13 of 15 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 1A k U e+C�m U� Property Address o 0 3 u i) s rvarrre mquWW for AAA- every page. State' ZippCCode Date of nspecHon�r' D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. L _ - . I l i CZ— �2l G i 00 *nsp doc•one Title 5 Official Ins pection Form:Subsurface Sewage Diepotel System•Pepe 14 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M� Li 2�m C1�-- Property Address T ` \) OvMes Naine A�a information is �� r ��LLI 1 1 1 U-7 required for every pap, Cityrrovrn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells n Estimated depth to ground water. feet v\� 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: a �e-<-�Ij �ep�l� �►'uf ��} S bo w eJ arovlJ 3-C4 6,11 . o AA"c o fC t5insp.doc•08I08 Title 5 Official InspecUm Form:Subsurface Sewspe Disposal System•Pape 15 of 15