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Home My WebLink About0045 DUNASKIN ROAD - Health 45 Dunaskin Road, A= 228 -018 Centerville �j SMEAD No.2-153LOR UPC 12534 smsad.aom • Mad*In USA O;F1 �11ESFiPY00RAMNO No. 20` O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Lol Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftphtatlon for BispoBal 6pstem Construction permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 14.5 D 1 jN q.-5141 0 P,*0 Owner's Name,Address,and Tel.No. C`V ica.� V/R�aoito GsH13A0Gi4 ,` Assessor's Map/Parcel �.5 DUk K f iG� Installer's Name,Address,and Tel.No.S 03-4.7l' 1"� Designer's Name,Address,and Tel.No. 1921 Type of Building: Dwelling No.of Bedrooms V" ' / Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 44 Design Flow(min.required) IV ft gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9kAt4' L4lug CUSS. Pui)(, TO L6(,K- - P[T Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He C Signed Date U to"/J Application Approved by Date Application Disapproved by Date for the following reasons Permit No. f 0( l Date Issued _�� 5 No.2G ( /IICI Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes _ 2pplicatimi for Disposal -pstem Construction Permit Application for a Permit to Construct( ) Repair(V Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. 14.5 DV N Ac5 Kt lU v> Owner's Name,Address,and Tel.No. V�C2T-,,chv�A GSNII�}tJ6eK �. Assessor'sMap/Parcel aag 012 C V I y l RD Z4 Installer's Name,Address,and Tel. o.$D,2-47'i-0&1'7 Designer's Name,Address,and Tel.No. CAVEWM6 SW-rtY PR15� IL— 01 A Type of Building: Dwelling No.of Bedrooms v Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures An Design Flow(min.required) gpd Design flow provided / gpd Plan Date Number of sheets Revision Date Title °`, Size of Septic Tank Type of S.A.S. y Description of Soil Nature of Repairs or Alterations(Answer when applicable) ae�� L W19- F&M SSf�[.��- ?'mil L&k* p t r Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He zh. Signed Date Application Approved by Date C� _ro - tS Application Disapproved by Date for the following reasons Permit No. C9 0�s Date Issued �a 5 ----------;---------------------------------- ----------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by C PGh D6 Eh1MWIQ � U—C, at 4V-1 UAJAS Kt&J 91) C t l/(u-05 has been constructed in accordance -with the provisions of Title 5 and the for Disposal System Construction Permit No.dO S' T -dated Installer ( ( Designer N t #bedrooms Approved design-flow �� gpd' The issuance of th" pernpit shall not be construed as a guarantee that the system willlfunctionlasl designe . Date r ( Inspector --- ----------------------------------------------------------------------------- -------------------------Fee------------------- No. o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction �erntit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at T 5CWAS'(C!A 1 A d 7C0 &E)� � t L and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date — Approved !�-��--/[� 1 by i un 19 1510:22p p.1 Commonwealth of Massachusetts M � � fa�g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner owner's Name information required for every Centerville Mkt 02632 6-18-15 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form.Mspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information filling out forms /'�/ / �+�t}�OFr►ilTgsq''. on the computer, use only the tab 1. Inspector: _�� • 'q�,y key to move your r O • G cursor-do not James D.Sears JAMES im use the return Name of Inspector = a key. CapewideEnterprises,LLC �1 Company Name 153 Commercial Street Company Address Mashpee MA 02549 Cityrrown State Zip Code 508477-8877 S 1623 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 Q� 6-18-15 effispector'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 inspectio, does not address how the system will perform in the future under the same or different cond:,,';ions of use. t5ins•3/13 TII19 5 Official Inspection form:Subsurface Sewage Disposal SYslem•Page 1 of 17 Jun 19 1510:22p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owners Name information required for every Centerville MA 02632 6-18-15 page. Cityy1rown 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: Front System The system is a block pool and pit. 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 lank is metal and over 20 years oJd*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 ❑ NO(Expfain belowl: t5ins•3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 2 of 17 Jun 19 1510:22p p.3 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. Cityfrown State Zip Code Date of Inspedion B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The 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 5D feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15in3.3/13 Title 5 Orrcial Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Jun 19 1510:23p p.4 N. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centemile MA 02632 6-18-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 systern 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 N1C}❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in eis less than 6" below invert or available volume is less than try day flow /'i T t5ins-3113 Titre 5 OlBdal Inspection Form:Subsudace Sewage Disposal System-Page 4 of 17 Jun 19 1510:23p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owners Name information required for every CenteMUe MA 02632 6-18-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.3 ❑ ® 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 e0er"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 railed.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•3113 Title 5 Official rnapection Form:Subsurface Sewage Disposal System•Page 5 of 17 Jun 19 15 10:23p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centieryiii'e MA 02632 6-16-15 page, Cdyrrown 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 NIA) ❑ 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 91pNoMmanholes uncovered, opened,and the interior inspected for the condition of the tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 0 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 15.3W(5)] D. System Its#ormation Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3115 Title 5 Ofiidal Inspection Form:Subsurface Sewage Disposal Systam-Page 6 or 17 Jun 19 1510:24p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments UV 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA 02632 6-18-1 5 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a block pool and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013-50,000Gal g ( y g (gp )) 2014-53,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciallIndustrial 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: t5ns.3113 Title 5 Official Inspection Fonn:Subsurfma Sewage Disposal System-page 7 of 17 Jun 19 1510:24p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every CenterAlte AAA 02632 6-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2014 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: ® qEaamwzaa= soil absorption system ® @WV6 cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank_Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 TrUe 6 official Inspeaticn Forth:Subsurface Sewage Disposal System•Page 8 of 17 Jun 19 1510:24p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner owner's Name information required for every CerrterviNe MA 02632 6-IP-15 page. City/Town State Zip Code Date of inspection D. System information (cont.) Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' 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_): Pipeing is orange burge and PVC. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5in3•3l13 Title 5 Official 6rispection Form:Subsurface Sewage Disposal System•Page 9 of 17 Jun 19 15 10:25p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owners Name information is required for every Cente Wife MA Q2632 6-48-15 page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle f Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3113 Title 5 Of oal Inspection Foam SubsurfarA Sewage Disposal System-Page 10 of 17 Jun 19 1510:25p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: © concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc,): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 6 official Inspection Fotm:Subsurfaco Seerage,Disposal System.Page 11 of 17 Jun 191510:25p p.12 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w _45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information is required for every Cerrtervide MA 02632 6-16-15 page. Cityrrown State Zip Code Date o.Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc,): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Jun 19 1510:26p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number 1 ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ inn ovativelaltemative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation., etc.): Leaching is a 1000 Gal. Precast Pit. Pit at 40"below grade w/cover at 8". Pit is clean w/wet bottom, Wall's are clean,like new. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth —top of liquid to inlet invert Z Depth of solids layer 3 r 1" Depth of scum layer Dimensions of cesspool 6'Deep Materials of construction Black Indication of groundwater inflow ❑ Yes No 15ins•3113 Title 5 Official hspaction Form:Subsurface Sewage Disposal System•Page 13 of 17 Jun 191510:26p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owners Name information is required for every Centerville MA 02632 6-18-15 page. City/Town State Zip Code Dale of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool 6' Deep bock wkcver at 20"one tine in,no Tee. Out let PVC Tee. 3'water in pool. Privy(locate on site Alan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15Ins•3M3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Jun 19 1510:26p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh Owner Owner's Name information is required for every Centerville MA 02632 6-18-15 page. Cityrrown State Zip Code Date of Inspection 0. System Information (cont.) 5y5 Ti bKetctl 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. P_f=j 9 ❑ hand-sketch in the area below drawing attached separately -1 = 3`f le A-1= 3� Ys�"£�t 94 r 6-' 31" 8 -3 - -34—q' �+ 5 Y51 f A all rg a,vim i� p vS K /`3� 3.- z�— �' YsEM 5Y3-7-f ti G� 61 t&ns-3R3 Title 5 Offical Yeped im Form:SuDsurram Sewege Disposal System.Pago 15 0 17 2 Jun 19 1510:27p p.16 Commonwealth of Massachusetts - Title 5 Official Inspection Form a 6 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Dunaskin Road-Front System Property Address Virginia Eshbaugh _ Owner Owner's Name information is Centervift MA 02632 6-16-15 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ' 14' 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: i You must describe how you established the high ground water elevation: Auger T.H. 14' no G.W. Bottom of pit at 4'above T.H. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Jun 19 15 10:27p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -Front System Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA 02632 6-18-15 required for 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 fife !sins-3r13 Title 5 official Inspection Form:Subsurface&,age Dlsposai System•Page 17 of 17 Jun 19 1510:27p p.18 .Ere/V + oc OF 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r�o r 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Esh_baugh ___ U1 Owner Owner's Name . information is Centerville AAA 02632 6-18-15 required for every page. Cityfrown State Zip Code Date of inspection 1 InspeeWn results must be subtlnitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. Important:When Q- General Information filling out forms ��``�tN OF IA4,1`rS on the computer, /U � ��•��. use only the tab 1. Inspector: �0- �.. r- ��- key to move your =�: JAMES '-.%S cursor-do not James D Sears sEAr)S use the return Name of Inspector '" key. = Capewide Enterprises,LLC � Company Name ��i G N / HtII15 \`. 153 Commercial Street Company Address Mashpee MA 02649 City/town State Zip Code 508-477-8877 S1623 Telephone Number license Number S. Cet;tificatio� 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority � 6-18-15 spectoft 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 wO1 perform in the future under the same or different conditions of use. 15ire-1113 Title 5 Official trtspedion Form:Sutuurboe sewage Disposal System-Page 1 of 17 Jun 19 15 10:28p p.19 Commonwealth of Massachusetts Title 5 Official Inspection Form * Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is MA 02632 5-16-Z$ required for every Centerville page. CitylTown State Zip Code Date of Inspection B. Certification (cunt.) 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: Left side system#1 The system is a block c pool and pit. 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 [] NO(Explain below). t5ins-3113 Title 5Official Inspection Forth:Subsurface Sewage Diwosel System•Page 2 of 17 f Jun 19 1510:28p p.20 Commonwealth of Massachusetts isjwo Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U1W- 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA W632 6-18-15 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(cant.): ❑ 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.3r13 Title 5 Omdal Inspection Fam:subsurface Sewage Disposal Systern-Page 3 of 17 i Jun 191510:28p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments — t 1 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner owners Name information is Centerville AAA 02632 6-16-15 required for every page. CItylTown State Zip Code Date of Inspection B. Certification (cunt.) 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 5 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 Beet 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 a Q ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Q ® Liquid depth in is less than 6" below invert or available volume is less than Y2 day flow /0/7— t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Jun 19 1510:29p p.22 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville 02632 6-18-15 required for every 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 CDEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammorria 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 faits. 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•3113 Title 5 Official Inspection Farm:Subsurlaee Sewage Disposal System-Page 5 a117 Jun 19 15 10:30p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh _ Owner Owner's Name information is Centerville MA 02632 6-f 8-15 required for every 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 NIA) 0 ❑ 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 950IMMER manholes uncovered, opened, and the interior inspected for the condition of the tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 0 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)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5lns•3113 Tile 5 Official Inspection Forth:Subsudece Sewage Disposal System•Page 6 of 17 Jun 19 1510:30p p.24 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA 02632 6-18-15 required for every State Zip Code Date of Inspection page, CitylTtwvn D. System Information Description: The system is a block c pool and pit- Number of current residents: eDoes residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (include laundry system inspection: ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No ' Wafer meter readings, if available (last 2 years usage (gpd)); 2013-50,00OGaIs2014-53,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date i F Commerciallindustrial 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: 15ins-3113 Trtfe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 0 17 Jun 19 1510:30p p.25 Commonwealth of Massachusetts Title 5 Official Inspection Form A I. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is required for every Centerville MA 02632 6-18-15 page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): e i I j General Information Pumping Records: Source of information: 2014 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, 1112MMINIM soil absorption system t ® Moffibcesspool ❑ 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): 15ins.3A3 Title 5 Official Iropadon Form:Subsurface Sewage Disposal System-Page 8 of 17 Jun 19 1510:31 p p.26 Commonwealth of Massachusetts Title 5 Official Inspection Form ro Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is CenterviNe MA 02632 6-18-13 required for every page. CiblTown State Zip Code Date of Inspedion D. System Information (cont.) 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 Building Sewer(locate on site plan): 30e Depth below grade: feet Material of construction: ® cast iron ® Q PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is cast iron and PVC. New line main pool to pit 6-2015. Septic Tank(locate on site plan): 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: Sludge depth: 15ins•3113 Trtle 5 official Inspection Ferm;Subsurrace Sewage Disposal System•Page 9 of V Jun 19 1510:31 p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Propeny Address Virginia Eshbau h Owner Owner's Name information required for every CentervPNe MA 02632 6-18-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cost_) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-3113 Title 5 Offidal Inspedion Form:Subsurface Sewage Disposal System•Page 10 or 17 Jun 191510:32p p.28 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is Cerrtenril�e MA 02632 6-18-15 required for every page. CityFrown State Zip Code Date of Inspection D. System Information (coat.) 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•3113 Thle 5 oificlal lnspectlon Form:Subsurtace Sewage Dtspcsal System•Page 11 of 17 f Jun 191510:32p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is required for every Centerville AAA 02632 6-18-15 page. CitylTown 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 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.): i r - 3 t i 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.): I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form.SLbsurface Sewage Disposal System•Page 12 of 17 Jun 191510:32p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA 02632 6-f 8-15 required for every page. City/Town State Zip Code Dale of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number. — ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 6' precast pit. Pit at 30" below grade w/cover at 1'. 2'water in pit w/stain line at 3'. No sign of over loading or solid carry over. No high Stan line, clean wail's. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 6" Depth—top of liquid to inlet invert f Depth of solids layer 311 Depth of scum layer 1 Dimensions of cesspool 6' Deep Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Tllle 5 Official inspection Form:Subsurfain Sewage Disposal System•Page 13 of 17 Jun 191510:32p p.31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name Information required for every CentteMlile MA 02632 6-18-15 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.): Main pool is 6'block w/covier at 16".One fine in cast iron, No tee. Outlet line w/PVC tree. 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•3f13 7itte 5 Official tupection Form Sdmrface Sewage Disposal System•Pape 14 of 17 Jun 19 1510:33p p.32 Commonwealth of Massachusetts 1 Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System U9., Propeny Address Virginia Eshbaugh Owner Ormees Name --- — informetiort is required€or eyer, Centerville MA 02632 6-18-15 page. O ry>Town State Zip Code Date of Inspection D. System information (cons.) !"71— , _t �dPrf:r1 LGw 9nn rnr.c i C...:..«.. C].....:.,_ - ,::_..__r..-- -- - •. . y5 -� 5cetcn tSewage I�isposa�l System: Provide a view of ks or benchmthe sewage disposal system, including ties to at least two permanent reference landmararks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes beJovr_ . _/ ❑ hand-sketch in the area below ❑ drawing attached separately Q_, _ 34-f- /4-3= 3 F.` '5 5,FE A 13 .s Ys!f AA I r O -3 _ -3 i _ I YfA � � o ream �a�T �= j` 5 K 5M j Q f r �Nr I- 5 Ys 1Im o L 15ins-3013 Title 5 Off KW kapedion Form:Suflswface SuwWe Uispcsai System•Psge 15 Off 7 f Jun 19 1510:33p p.33 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 45 Dunaskin Road -(Left Side System 1) Property Address Virginia Eshbaugh Owner Owners Name information required for every Centerville MA 02632 6-18-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells P0 Estimated depth to high ground water: 14' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record It checked, date of design plan reviewed: Date ❑ Observed site(abutting propertylobservation 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: Auger T.H_ 14' no G.W. bottom of pit at 4' above T.H.. Before filing this Inspection Report,please see Report Completeness Checklist on next page: t5ins-3M3 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Jun 19 1510:33p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 1) Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Q{ 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-3113 Title 5 Olfidai lnspadion Form:Subaurraw Sewage Dis l System•Page 17 of 17 r 3 a h 3 Commonwealth of Massachusetts Title 5 Official M�� /� c al Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Propeny Address Virginia Eshbaugh Owner Owner's Name information is Centerville MA 02632 5-18-?5 required for 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 formsA. Genera} information on the com �� D U� H OF 414sr ter, OF ii key to move your use only the tab 1. Inspector: `,moo=S'�'� s�o�G., W rsor-do not JA M E S use the return ,lames D.Sears _ Name of Inspector y, CapewideEnterprises,LLC o o —� Company Name �' > ' . 153 Commercial Street '�,F 5 Company Address -- Wash pee MA 02649 CityrFown State Zip Code 508-477-,H77 S1623 Telephone Number License Number B. Certification 1 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 andina`irii dance of n site sewage disposal systems. I am a DEP ate�_ }`��g p y approved system inspector pursuant to Section 15'.�40 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving'Authority spector'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 wici perform in the future under the same or different conditions of use. 15ins•3113 Title 5 Official Inspection Form:Suasufece Sewage Disposat System-Page 1 of 17 I•'d eLZ:OI 96 OZ un Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 2) Property Address — Virginia Eshbaugh Owner Owners Name information required for every Centerville AAA 02632 6-18-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: I have not found any infiormation 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: _Left side system#2. The system is a block c pool and pit. 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 over20 years oJd* 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): 613•3113 Tine 5 Official Inspection Form:Subsurface Sewage D" System•Page 2 of 17 Z'd eLZ:06 96 OZ unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information is required for every CenteMite MA 02632 6-18-15 page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The 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): L] 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: II 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-3113 Title 5 Official Inspection Forth:Sutsudace Sewage Disposal System-Page 3 of 17 £'d e8Z:06 9l, OZ unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 2) Property Address _Virginia Eshbaugh Owner Owners Name information is required for every Centervite AAA 02632 6-18-15 - page. Cityrrown 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 atieched 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 N� ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in easelift is less than 6" below invert or available volume is less than'/day flow P,T 15ins•3113 Tdle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 t,,d e8Z:0L 9l• OZ unr Commonwealth of Massachusetts a. �.; WA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 e page. City/Town State Zip Code Dale 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. El ® 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 3 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 foltowing, 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. 15ins•3l13 Title S Ofridal Inspedon Fours Subsurface Sewage Disposal system•Page 5 of 11 5"d e8Z:06 9l, OZ unr Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name informationis required for every Certitervflle MA 02632 6-18-15 page. City[Town State Zip Code Date of Inspection C. checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as NIA) ❑ Was the facility or dweiiing 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 m2pLINES manholes uncovered, opened, and the interior inspected for the condition of the 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)1310 CMR 15.302(5)) D. System tn#ormation Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Uisposal System•Page 6 of 17 9-d e67,:O6 9l OZ unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owners flame information a Centerville MA 02632 6-18-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a block c pool and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes }gl No 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 2013-50,000Gals g y g (gp )) 2014-53,OOOGal's Detail Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial 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. t5crs•3113 Title 5 Ofrrcial Inspecian Form:Srbsurface Sewage Disposal System•Page 7 of 17 L'd e6Z:O1,91, OZ unr. Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _45 Dunas_kin Road-(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information is required for every Centerville MA 02632 6-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2014 Was system pumped as part of the inspection? Q Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? 'Reason foT pumping: Type of System: fit, soil absorption system 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 Q Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Tille 5 Official Insped ion Farm:Subsurface Sewage OWposal Syslem•Page 8 of 27 9-d e6Z:01.91. OZ unf Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information is Centervilte MA 02632 6-18-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade. 30" feel 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.): Pipeing is cast iron and PVC. Septic Tank (locate on site plan): 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: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or 17 6-d e0£:0L 9l, OZ unf Commonwealth of Massachusetts Title 5 official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Propeny Address Virginia Eshbaugh Owner Owner's Name information is required for every Centerville MA 02632 6-18-15 page. Citylrown 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 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 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•3113 TWe 50ffidal hspedionFonn Subsurface Sewage Disposal System•Page 10 of 17 0�'d e0£:01, 9 6 OZ unr Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information required for every CenteMflie MA 02632 6-18-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 15ins,3113 Title 5 Offidal Inspection Forth:Sutsurface Sewage Disposal Syslem-Page 11 or17 1,6,d e00:01.91• OZ unf Commonwealth of Massachusetts Title 5 Official Inspection Form _ Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Fshbaugh Owner Owner's Name information a Centiamille BRA 02632 6-18-15 required for every 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 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Now Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsiafaoe Sewage Disposal System-Page 12 of 17 ZL-d e[C:01,51, OZunf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. Cityrrown 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: ❑ 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 is a 6' precast pit. Pit at 37" below grade w/cover at 4". 1'water in pit No sign of over loading or solid carry over. No High stain line, clean wall's. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): 1 Number and configuration Depth—top of liquid to inlet invert 1' 3" Depth of solids layer 1" Depth of scum layer Dimensions of cesspool 7' Deep Materials of construction Block Indication of groundwater inflow ❑ Yes No t5ins-3113 Title 5Official trispection Form:Subsufam Sewage Disposal System•Pape 13 of 17 £l'd el£:0l, 9l• 0Zunr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road-(Left Side System 2) Property Address _Virginia Eshbaugh Owner Owner's Name information is Certtenrille MA 02632 6-18-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Main poor is Tblook wkaoverat 15". One line in, No tee. Outlet tee. 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.3J13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 94 of 17 9l'd eZ£:01.91 OZ unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 45 Dunaskin Road-Left Side System 2) Property Address Virginia Eshb_au_gh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 -- _..--•-- — --- - page. Cityrrowr. Slate Zip Code Date of inspection D. System Information (cont.) S YS M SKetcn Of Selvage 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: 9 ❑ hand-sketch in the area below 'J ❑ drawing attached separately 9-1 - 311 J ' �G ------� 5 Ysi F - � jo vPT , a- 3. -. I P A �i- i U s Y5-' T 5iaE i t 5YSifoi L t5ma•3113 TiUe 5 Official h3poaicn Form:Subsurface Sorape Disposal System•Pago 15 or 17 9l'd eZ`:o0 91. OZ unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Address Virginia Eshbaugh Owner Owner's Name informationis required for every Centerville MA 02632 6-18-15 page. CityrFown State Zip Code Date of Inspection D. System Information (cont,) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells C � 14' 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: Auger T H. 14'no G.W. Bottom of pit at 4'above T_H_ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•M3 Thies Official Inspecdon Form:Subsurface Sewage Disposed System-Pege Ze of 17 L l•'d eZ£:0L 91. OZ unr. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 45 Dunaskin Road -(Left Side System 2) Property Aadress Virginia Eshbaugh Owner Owner's Name information required for every Centerville MA 02632 6-18-15 page. cityfrown 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•3113 Tills 5 Official Inspection Form Subsurface Sewage Disposal System•Page W of 17 86'd eZ0:0I 9L OZ unr r! INKFimic THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... �-................0F........o>PAA..�, r..........------.._..........--------- Appliration for Uiipniitti Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct ( or Repair (.d-) an Individual Sewage Disposal Systemat: ............................................................. FSYX{Gta4Cse':i�... Location•Addres or Lot No i/ / j 4 Lr O wner re s a � l1Arht�. 4 ....... Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.......... �"!` ..................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ...... No. of persons............................ Showers — Cafeteria Q' Other fixtures ...................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W ' 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........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----.....-........................................................................................ 0 Description of Soil............... .-------••-•........................••------------------•-•----...-------------•-------------------•-------•......•-••••--- W V --•---------------••----•••--------••-••................•-----•----------------•--------.......-•-----•-•---•--•------...---------••--•---•----•------------........---•--------•----•--••••------•----- W -•---•-•-•-•----------------••---•••-•----•--------••--•------------•------------•----•.....-••--•••---••-----•-•---••------•-••-•-••-•--•-•-•-------•---•..:--••---....._........-•-•••---------------- U Nature of Repairs or Alterations—Answer when applicable------O!q.9-------- _v.£ tJ .......................................................O Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TAITLU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sued by t board of health. g .��...�....Sindtasons: .. ..-•- -•------------ ----- - ---••--------•---•---•----.......--- �S- Date Application Approved BY --........E Date Application Disapproved for the ollowing •-----------•-•-----------•------••----•-•--•-••.....••••••------•------•------••--•--•---•....------•-•--••-•-- ••........................••-----------•-----••-•------•------...............-••------........---------.... ------...•-------- Date PermitNo......................................................... Issued....................................................... Date �, THE COMMONWEALTH OF MASSACHUSETTS - -�` BOARD OF HEALTH ................OF....... Appliratiou for Ui pooal Works Tonstrurtion rnmit Application is hereby made for a Permit to Construct ( ) or Repair (L-) an Individual Sewage Disposal System at ...�.z' ... �. ?I................................ ........ Lo �, . . ........ :..... cation,-Addres or Lot N ------- -- ..... .._. ...- - .. .............. Owner ddress w ... = - 1. ---�r " Installer Address U Type g ` = Size Lot............................Sq. feet T e of Building ♦ ,., DwellingNo. of Bedrooms_______________.......... ________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons____________________________ Showers G-1 yP g --------•------•---•-------• P ( ) — Cafeteria ( ) 44 Other fixtures ..............•-•--•-••--_---•• - W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity...:........gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 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....................... G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------- ----------- --------------- ---------------- •----------------- •------------ •••--------------------- •--------------- DDescription of Soil .!K-w^ . •-•--------.............................................................................................................. x w VNature of Repairs or Alterations—Answer when applicable.......QNg O�£q2 IrIA �t ••_ :.................................... ..•---••----••••---••••-••---••.....••••-•-•••--•--•-•••--•-•-••-•-•--•=-•-•----•--•.......••••-•••------•--------•-•--•------••--•---•---•----•••----••••-•-•••-••••••--•-•--•-•----••.....••••••..._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code The undersigned further agrees not to place the system in P P g -• -_y -- -- health. •,-operation until a Certificate of Compliance has bee sued b th board of sln - •-• °t 7.. .......... ........................ Date Application Approved By•••---------• ••---•••-•---• •-•--- _ •----•• •...•----- � Date Application Disapproved for the following sons:.-•---------•---••-----------------------------------------•-•-------------•----------••--•--•-...._..__._.... ............................................--...................................................................-------•-----=----•••------••-•--•-•--•--•-••-•-••--•----•-•••--•---••••--•-•••••-•••- Date PermitNo........................................................ Issued....................................................... -- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ... ? .........-....oF...................:�."V..�4._._._.._........................ Tntif iratr of Tomplittnrr T I IS TO CERTIFY, That the Indiv l Sewage Disposal System constructed ( ) or Repaired ( ) /,SGl�js9 Installer -- .,..... ............................................................. as been installed in accordance with the provisions of TITTL,E� of The State Sanitary CodeJ� scribe in the applicatiog for Disposal Works Construction Permit No..-.�. ___r_o 8__._.. dated----------- _ _/.� �._.___(Z_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE AT THE ��XSTEIN WILL FU ............ : 'F,�QrI--, T�I,RSFACTORY11�1 � Inspector......_...�,~.�______________ DATE_....:.�' _ P-42- e ........... ,ram N IF-0 A PRrilmm-4-0-, THE COMMONWEALTH OF MASSACHUSETTS ��•o BOARD OF HEALTH �� ..!.. ............OF...-._... .d1Jl-!^� !�............................... r c �G► No......................... FEE.... Disposal Works � nofrurtion f rrntit Permission is hereby ........... ..,/u ... ._..::,--........................................... ... to Construct ( ) or Repair (k) an Individual Sewage Disposal System at No....................... '�-_S------•••--•,- --W--�1-S,1eIIV-•---�►b-t-----------------�..Vt_1..te ......... ..... Street as shown on the application for Disposal Works Construction Permit No_______ ____________ Dated....... "�(�0 i ....................................... oard of Health +Cm44•`�•-•%.......... . DATE........_•-•-•- .:-- ..... ............:_ _.. t FORM 1255 A. M. SULKIN, INC.. BOSTON d� JOSEPH P. MACOMBER &SONJNQ. Tanks-Cesspools- Leachfields Pumped & Installed Town Sewer Connections DATE P. 0. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 ............. ........... . f � ,��x �� ,/� _ ...... .... TERMS: PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ DATE I INVOICE NUMBER/DESCRIPTION ( CMARdE$ CREpITS I BALANCE BALANCE FORWARD /tla-.74�.....,......... _ ._.. __.. ...... ................... ................. ... .... ...... _ • 1. ,1„sfair ��F �-� -S" ;,ASSESSOR'S MAP NO._ii* PARCEL Ll0CATION fCl SEWAG PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS L19— Z:Q4,m-o AA es -A-L- IA,112 --D OR OWNER DATE PERMIT ISSUED JA _� �- DATE COMPLIANCE ISSUED IZ ~� ,� llif VA, ski let Aj P L No.......... .®..i Fics. ................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.. .t�J... ....O F.... . .......... Appliration -for Bi,ipoiittl Workii Tonfitrurtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: r Loca ion-Address t No. Owner Address Installer Addr� <� Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a'' Other fixtures ------------------------------------------------------ W Desi ow................... _______________________gallons per person per day. Total daily flow--------------------------------------------gallons. 9 eptic - Atnk—Liquid apacity............gallons Length................ Width................ Diameter_.__._.-------- Depth.__----__-.-.._ W Dispo sal Trench o_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. x ge it _____________________ Diameter-------------------- Depth below inlet-------------------- Total leaching area------------------sq. ft. Other Dis ution box ( ) Dosing tank (r Percolati Test Results Perfor by.- ______________________________________ Date_-__---------------------..------------. Test No. 1...... ------- i tes ino ept t it____________________ Depth to ground water_-._-.._--._-__------ f� Test t o. ...... P P P g _ � nut ' per inch Depth of Test Pit____________________ Depth to round water__._.....___.._....._._ � ------•----- --- -----------------------------•-------•-•-•--•---••-•----•---••---•--•._...__-----......................................................... O Descr ion f Soil---------------------- W x ----------- -------------------------------------------------------------------------------------------------------------------- --------------------------------- .......................... V Repairs or ter re of Repai Alterations—Answerwhen appl• le._._...Q?77..... . - - - -_-----. /�.Cg._✓( .. _ y l - L ---------- -P -------- Agreement: ��✓ ��T/f s The undersigned agrees to install the aforedescribed Individual Swage Disposal System in accordance with the provisions of Article \I of the State Sanitary Cod e rsi d further agrees not to pl e the st i operation until a Certificate of Compliance ha e iss dliy and Stgn _ ----- -• ------- . at Application Approved BY_ 1 -- -- ---- - --• - --- ----- 1� Date Application Disapproved for the following reasons------- - -- ------- - ---------------------------------------------------------------------------- --•--•---•-------------------•--•-----•-------------------------•----------------•-•-----------------------•--•-•••------•-----•-••-•-----------•-------...._...-•--•----------------•-•---.....__•--•- Date PermitNo......................................................... Issued....................................................... Date .............................•.....•......•.•.........•..•.............••.........•••.....•................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rje: 1..........O F.......�/...Q,t/LL...-................................................ f1rrtifiratr of OUNoutplianrr T IS, S TO E FY, That the Individual Sewage Disposal System constructed ( ) or Repaired by . . ---- / �` Instal A �'�'------- 4t.k_ l - --�-C'------ -------------------------------- has been installed in accordance with the provisions of . I of The State Sanitary Code as desc ibed in the application for Disposal Works Construction Permit N e_7_________________ dated.... -_�--. �_-_-_.__.__.__._ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector..... ., X . . ..... No........... .. Ficz.'�...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH k)qs- ....OF... — L 7; ........... Apphration -for Uhipoiial Worbi Tomitrurtion Prruift Application is hereby made for a Permit to Construct or Repair ( I—)—'anlridividual Sewage Disposal System at: r Ic ............* 14J Fe- ...................... IV C kDTaf -..... ........... ..................... . ....... ........................................ Location-Address .. ........................................................ Owner Address ........................ "dr'e"ss Installer Ad Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms----------------------------------...___..__Expansion Attic Garbage Grinder �1 a4 Other—Type of Building ---------------------------- No. of persons--__________________________ Showers Cafeteria Otherfixtures -------------------------------------------------------------------------------------------------------------------------------------------------- W DesignFlow___________________........................gallons per person per day. Total daily flow............................................gallons. ep t'ic nk capacity------------gallons Length________________ Width-_._---_...-_.. Diameter_-___.--..__.__ Depth-__-_-____--_. : _ Disposal Trench No. .................... Width_____________-___-_Total Length_.. ........._..__...... Total leaching area....................sq. ft. Seepage it --------------------- Diameter__.____...._._.____. Depth below inlet__.___._______._____ Total leaching area------------------sq. ft. Other Di ibution box Dosing tank Percolati Test Results Performed by, ......................................... Date__---_---------------------------------. ,� Test No. I...... i utes 'Dep-k-U----Cc�Pit.................... Depth to -round water_:-___---_________.._.. r14 Test t . .......��.' __n nu s per inch Depth of Test Pit____________________ Depth to ground water..._..._.___-_-_____---. 9 6------------------------------------------------------- ............................................................................... 0 Descr tion f Soil__-_ x ------------------------------- IJ ----------------- --- --------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ -------------------------------------------------------------------------------------------- N-ftture-of Repairs or Alterations—Answ r when applicable.......1-21 :7..... U - — (:T............ .......... ------- ..•j------jo��A�--------0_1�4—-------�_V.j... ------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code'_ ode ' he trdersi ed further agrees not to pl ce the syst'm i operation until a Certificate of Compliance has-been is e4-b e oard__of;.h,@a4t-ri— "I SignO, �,-- -- ---- ----------- ---------------- ...Application Approved By.__...___- D. 7 j— ....... .. ... .................. ---------------------------------------- Date Application Disapproved for the following reasons:--------------- ...... _----------------------------------------------------------------------------------- ---------------------------------------------__--------------------------------------------------------------------------------------------------------------------------------------- ---------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. .......0 F...... ... ....................................................... AT Qwrtifiratr of W"I'lomViianre IS IS dual Sewage Disposal System constructed or Repaired 0_" by ............ ------------- .................................................................. Inst.al'Er ; 4- .......... --- at..... ----Z ----- 4,K) has been installed in accordance with the provisions of of The State Sanitary Code as described in the application for Disposal Works Construction Permit N 7 '_(-------------------- dated. .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................. ......... Inspector /61 =................. THE COMMONWEALTH�_OF MASSACHUSETTS BOARD OF HEALTH ............................................................. No..................... FEE_-Z�............... ------------ Permission is hereby granted--- ....... .................................................. to Construct ),-or Repair an Individual-Sewage Disposal System atNo. 5S_-----�L. ....... ------------------------------------------------------------------------------------------------------ Street as shown on the application for Disposal Works Construction WPeprny'Jit No_____ ated.......................................... .......... -- -- ------- - ----------- ................. Board of Health DATE................................................................................ FORM 1255 HOE38S & WARREN. INC.. PUBLISHERS w, Fv2►v s Nc�Q v 46me .J -` l0 C A T ION SEWAGE PERMIT NO. ;-� 45 �VN�SK ii�l I�CoAb VILLAGE Gt---rAT-cR� t I N S T A LLER'S NAME i ADDRESS f JosEpV4 F, „z, 1 6 . $ox ao B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r I�� y n i Ce5SQoo I o Prr