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HomeMy WebLinkAbout0494 ELLIOTT ROAD - Health 494 Elliott Road Centerville A= 227-117 ME:A D No.2453LOR UPC 12W smsad cm • Ysdt In UGA SO). sW imaoum m m a mOmmlam OFI I / 3 r i 1 I 3 i t Commonwealth of Massachusettsa-- rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7= — ' 494 ELLIOTT RD _.. Property Address ANN PETERSON Owner Owner's Name information is CENTERVILLE MA 02632 12/8/2020 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. filling n A. Inspector Information fillip out forms on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return ---- ---- key. Company Name 350 Main St. rab Company Address W Yarmouth MA 02673 City/Town State Zip Code ary 508-775-2825 SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally'Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1..� ,P%� �/- 12/10/2020 Inspector's Signature Date i The system inspector,' shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicablle, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 1 of 18 t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v � 494 ELLIOTT RD Property Address ANN.PETERSON Owner Owner's Name information is required for every CENTERVILLE_ _MA 02632 12/8/2020 -- page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: SYSTEM IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t51nsp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage ge Disposal System Form Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tiii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;. 494 E_LLIO_TT_RD _ Property Address ANN P_E_TER_SON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool, ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less r than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ®. The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes °No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 15insp doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l� 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CEN_TERVILLE _MA 02632 12/8/2020 page City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions:- Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No J If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): '19- 123 GPD 18- 137 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date I 15insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 6/10/2020-CC SEPTIC SERVICES-2000 GALLONS Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' �l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANNPETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: UPGRADED IN 1995 PER PERMIT ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 49"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form �1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J a % 494 ELLIOTT RD Property Address ANN_PET_ER_SON Owner Owner's Name equir on is requiredd for every CENTERVILLE__ MA 02632 12/8/2020 r --__ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): . Depth below grade: 43"feet Material of construction: . ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) t If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 GALLONS Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 2000 GALLON H-20 RATED TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN, TANK AT NORMAL OPERATING LEVEL. COVERS 6" BELOW GRADE t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ,.h Commonwealth of Massachusetts =- Title 5 Official Inspection Form !p` ,,i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C, 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): - Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped.at time of,inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: I gallons Design Flow: gallons per day i5insp.uac•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments l�r j7 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE _ MA 02632 12/8/2020 —_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): NO,DISTRIBUTION BOX PRESENT t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -_- -,n Title 5 Official Inspection Form ,i 3 i Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments �;, 9 p Y Y 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every PEN MA 02632 12/8/2020 _-----_._... -------_.— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) '10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 1000 GALLON PUMP CHAMBER FOUND IN OPERATING CONDITION. FLOATS ARE IN GOOD CONDITION I * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): j If SAS not located, explain why: -------- --------- ------- Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions; 1-UNKNOWN ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ,riso iioc.•re, 712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts -- ,` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CE_NTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): LEACH FIELD WITH PERFERATED PIPE AND STONE INSTALLED ON PROPERTY. APPREARS TO BE IN GOOD CONDITION. NO PONDING OR VEGITATION PRESENT ON PROPERTY IN LEACHING AREA.EXACT LOCATION NOT FOUND DUE TO FIELD BEING PRESSURE FED FROM PUMP STATION AND NO DISTRIBUTION BOX PRESENT, 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts i Title 5 Official Inspection Form o, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l <1�a � 494 ELLIOTT RD Property Address ANN PET_ER_SON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 - page City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address ANN PETERSON Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I.�) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT RD Property Address _AN_N_PETER_SON Owner Owner's Name information is required for every CE_N_TERVILLE _MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope r ® Surface water ® Check cellar ® Shallow wells , Estimated depth to high ground water: +11'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: HAND AUGER TO 1 V WITH NO GROUNDWATER ENCOUNTERED. ESTIMATED DEPTH OF SAS NO MORE THAN 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151nsp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts • - -, Title 5 Official Inspection Form _ �1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 ELLIOTT_RD Property Address ANN PETERSO_N__ Owner Owner's Name information is required for every CENTERVILLE MA 02632 12/8/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A'. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 1212/2020 Assessing As-Built Cards `TOWN 0 I[ARNSTABLE �9 I/ LOCATION k.AeJ SEWAGE k zs-2GS' VILLAGE C!�K1tE_� � ASSESSOR'S.MAP Q LOT? I.NSTALLER'S NAME& PHONE NO. &A jJa Ltsf.Uj .o . Y-2e w40QI, 6.4 qf SEPTIC TANK CAPACITY Z000 Gs Tloco G LEACHING FACILITY:(type) (size) NO.OF BEDROOMS y PRIVATE WELL OR PUBLIC WATER 70"d BUILDER OR OWNER DATE PERMIT ISSUED: ��95 DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes No LS A10-1 - /41.1/ j Jos a,o ►- .S ATo�2 22 - zocc csT i a 8 'ia3 - 3lee s { 4 J�! s 'c.;wnofvan,stable us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=226192&seq=1 119 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere �J\ use the return key. Name of Inspector Cape Septic Inspections -El Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Citylrown State Zip Code 508-280-3356 S13938 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �,rA, 11/15/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name inormation is requiredforevery Centerville Ma. 02632 11/13/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,••°''` 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is Centerville required for every Ma. 02632 11/13/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•'' 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is every Centerville required foreve Ma. 02632 11/13/2013 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 attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is Centerville required for every Ma. 02632 11/13/2013 page. Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes [I No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2012 66,000 gallons used 2011 57,000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No i Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required uired for every Centerville Ma. 02632 11/13/2013 page. Cityrrown State Zip Code Date of-inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection coon Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22°feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 24"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: 2000 gallon septic 1000 gallon pump chamber „ Sludge depth: < 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for 9 p Y Voluntary Assessments •°° 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? field instruments 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information equir for is every Centerville required for eve Ma. 02632 11/13/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information equir for is every Centerville required for eve Ma. 02632 11l13/2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 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: apx40x9 ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is Centerville required for every Ma. 02632 11/13/2013 page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson er Owner's Name mation is fired for every Centerville Ma. 02632 11/13/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately v v �% o� I -To ► 87oz nx A 9"o 3 ^ Z 2 " 2eoe -' p -fe'/ - 3/5` ZL 8 To 3 — 3yC8 Ato S_3?• 3 i$ M '/- 5''-.1 I��Po S -no S— ySic 5� Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is required for every Centerville Ma. 02632 11/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet 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: I augared a hole to teen feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts w - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 M ,• 494 Elliott Rd Property Address Ann Peterson Owner Owner's Name information is Centerville required for every Ma. 02632 11/13/2013 page. CItyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r q � M rye v � " ° a 1:,.. _ 5 I � _�E �•o � Fa I 1! I a I �IN lif I I I. r 1 jr i ,,�!! I If!I.f IF I ..-y .� - y cg :E{$FF {6{(.r Eg€6 c+f E�Fcer P £•P{ gci{ Ici�FP.1Fl, ic•.�£{*�5��➢•a{ -<N''C .�- i all 71 � 1 I�: ._ 1 j l of 1 � i i rr- � ,1., 1-1 J ; 6 y A I — ; i I I a I ------- it I ( u I 13 I lam!'; tl �o w' NIF in III �Fl r a ��Rpc III ?�� . i lij �I I (; t� ale � �� •� vP J .n A.____._._._.Y PfTfRSOq fi1OU S Centerviller: Mai JYPKAG -L D E7J}/L '� � � .I. 'I / \� a�x � sowr.Uz•�/�o• � -} I — / \ ;tea. 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I _I__ 1 ----------- IN qq N L TOWN OF BRNS ATABLE . / LOCATIO 2- ALL to"Y koAri SEWAGE # T_5__ 2K_ VILLAGE cUxLL�' ASSESSOR'S .MAP & LOTS b INSTALLER'S NAME & PHONE NO. A, Pi 7 J�sbgja //- Z® w4G La,4 SEPTIC TANK CAPACITY Zo®® GST loon CAC preF 000e -4�c LEACHING FACILITYAtppe) C us ia7 (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED:�9S DATE COMPLIANCE ISSUED: �s- VARIANCE GRANTED: Yes No � a � 1 Uj f�1 Uv OA NO.. ...f 1...... 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tnnitrnrfinn 1hrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: f/ ---------�--9-y- ___...r.o .... �� �o Locatio Address or Lot No. C:_.......t �..s.f_ .X T c --------------- ---- -..S �tQ 'n ,� --.Q..S_� ✓u� e - Owner Address Pstaller Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms____.'3v� .__._Expansion Attic (/) Garbage Grinder ( )— '4 Other—Type of Buildin �L p� g `� _____________________ No. of persons..... Showers (3) Cafeteria ( ) P4 Other fixtures -----------•-------------------- - W Design Flow........... ....lll0___________...gal lons per person per day. Total daily flow___________-3_�4_.......................gallons. WSeptic Tank—Liquid capacity_ __gallon , L,ngth_10__il.______ Widths'_.?_______ Diameter________________ Depth____S g�� x Disposal Trench—No-_______�___________ Width_____�_3________ 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 ( ) 1000 6 A 110-j w r^P!"? `�` i�h Percolation Test Results Performed by.........Stpe11'Q__ _�_ .IAAS________________________________ Date........ ___ �?___________.___.___. Test Pit No. .....minutes per inch Depth of Test Pit.....1 y!_______ Depth to ground water_____Nv___ �!'� f=I Test Pit No. 2__-<_k______minutes per inch Depth of Test Pit_____!Z--- Depth to ground water.---ll__!5-----V .r/G 04 Ti - -•-••-•---- -------- r O Description of Soil---- �°$? .__ ._..__1............... .....�Y.?�!!!�..._ y___SUbSa I n G-_ _-_-- P -• Q). c�.---- x V upT s --•- ----------------•- �---------------------------- ••-• - ---- ----- -•- & -- b . .-••- ------ _..-X U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..-----•---•--•-----------•-••••-•--------•-------•--------•••-•-•--------------•--•--•--------•----•-------••--••--••---•--••••----•-•••-••----••--•----••--•-_...-•--••-••-•-••---.....••--•------•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .. .. .. ... `-- :1 G z9 �^'e ---- Application Approved By ---------------- --. .... l:e •�` Dace Application Disapproved for the following reasons: ....................... .................................................. ......................................------ -----------------------------------------------............................................................................. ---------- ----------------------------------------------- --------......................... Permit No. - � --------_-------_ Issued ----------- ------ ---------- ------------Dare Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cfer#tfira e of Compliance THIS IS TO CER IFY, Th i__�t the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ... : -- Insraller at ................. -- --- ----------- ------------------...--...--------------- ----------.-......------- --- ---..-..--....--------------------...---....---------------------------..--....-------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No- ------ 0--..`-. - --..-...-.... dated -----------------------------................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------- -- -- --------------------------------------------------------------------------- Inspector ------------------------ .-.-..-------...--•-------....----------------------- t ! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphration for Disposal Works Tnn,strurtinn- thrutit Application,is herebyy made for.a Permit-to Construct (%/) or Repair ( ) an Individual Sewage Disposal System at: , G /� Location-Address or Lot No. .._..._-1,.�"*11.4.w ,I . J.. .g't'f -----"� -�- !'. s4l _ ,11 .e /.. 1�.---.. •e 4- / e. �I r: Owner J Address nsller Address Type of Building Size Lot----------------------------Sq. feet a , Dwelling—No. of Bedroon)&,4 1-je_ -----------------------I-I-ExpansiSm Attic ( ) garbage Grinder ( ) p.I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a d Oth ,; ', turpas(r•-••---•-•------•--------•----•--------------- - •-• �-=„�-�-s�----------••--•-•---•---•----....---• W Design Flow................................�g,) __--gallons per persopr day. Total dily flow............................................gal%lore's. WSeptic Tank—Liquid capacity.'u,!---gallon, Length................ Width................ Diameter................ Depth................ x Disposal Trench—No........ ---.__-_- Width__.__.�.3.__..... Total Length...... ........ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (V Dosing tank ( ) 1000 6 A lla ����J�� Gam• J ` Percolation Test Results Performed by...__.___S�"e_Lhe..._.�AAA................................. Date.......7 b ". P / P ground 7r....•ti a .✓ � Test Pit No. 1.�._�.___..minutes per inch De th of Test Pit._____?''__.._..__ Depth to water..... i fs, Test Pit No. 2--<-y......minutes per inch Depth of Test Pit-__-_!.?s._._.___. Depth to ground water----AJ_-6-___W—d' �+ = _ = ------ --- -.............................._..._..-'o.......... O Description of Soil.... PSf ......•I------- -----5----�vcwa....�;.y �vbSo,��*+ �"nC ���'.......�&��..... x c, F - _ �'Sf--, 4 -V j._�__.13�uwa '�"' r `"� Fir{ r14 SA p W ---------------------------------- ......•. U Nature of Repairs or Alterations—Answer when applicable...................................................•............................._...._........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE S of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenC.*ssued by the board of health. •°` uiw 9 0 Signed ----- --------- ---- --------------------- ---------_---~o�...�� - -- .------..... --- _ --------Z.. . D-- .................. ace t Application Approved By ----.`�- .� "'4� -u.,.."" ------ --- ' l Date Application Disapproved for the following reasons- ................................................................................._.................................................... ........................................------------------------------------------------------------------------------------------------------------------- - ................................ --- --------------------------------------- p. Date Permit No. ........... .--------- :/ ------ Issued ------------------------- ................. ---------... Date f,- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ( TOWN OF BARNSTABLE (fertifira#e of C�nmyltttnre THIS IS CERTIFY Th t the Individual Sewage Disposal System constructed-(l or Repaired 90 g P Y ) ( > y Ins[aller S has been-installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..-- e�........3.,9.......... dated ................................................ T,.HE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �.---n ` -1 DATE........ . .................s .- Inspector. t .-•4 r 't ............................................................-----..-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C�G 3CI TOWN OF BARNSTABLE , No._........•-_---. FEE. ....... Disposal WorksTonstrurtilon frrmit Permission is hereby granted......... .............................................................. to Construct (>C) or Repair ( �) an Individual Sewage Disposal System at No....•.... ........./��>I '� ......._E4/ ��....---�y° J ............................................ Street as shown on the application for Disposal Works Construction Xermit N. .��� .3.�_ Dated.......................................... ._� ...........................................................Board of Health DATE----"----•-r�-.--I•^---•- - FORM 36508 HOBBS h WARREN.INC..PUBLISHERS I � - 1 _ '_ % I 4 a 3 Pi P P+Tc t�s �,�q /FT u►.1t.EX d1��W15E r ie7T'C+7. �'`�., ,, ,�✓' /' --/ --�" / f _ -, s ' 4. C�5'G nl t.UQD �'= a I.L PeE�ar u ni l-t3 alb oa _ f 0- -44 y S. rlPS OIIIlZS SFAAL.L BE MADE wA-is7-^rt6o+T. / 1 i�'`► _.o.1sTrZVLT�c�L DETo.+L:s To BE v.! o.cco2tC.E (rli tN /.i ..-'`' `-"" � �''' / ,.,,.� �' a a :..L,ng� / �� �':i : •. �:)4'=. . : ���. �nl�t�P1�.iM�t�Tf1L GoC� `C-Cc"t-E l� � _ --� "j. T+�t�-PLC 'FoQ PRoPvSED ��. o�t.( A►•l D S+�ov�.v w � / � � � � e_ ,__ � G' I C'v l ��' •� R�tUr GCE l,y�Efl Got P1�t�PE-22'C`(U�E 5't1�.►c..i a1Cs. / �--- �/ � - .; _�- ------------ --.-- _ � � � ' n1� � �,�I�*Ir,..il�r �-�r.r!.�.:, (t•.r.��.i rim' Pr,A� Ole Lj\ —2'rnFPaa�t-oa�--- / N• J i A45P7WEbSTo+.IE- . : 17 -- - -- rAc t L.c T1' f / / i / 42 2 G4L ! use ? �= GALLC� -ra"K. If IN, \ ✓+� rsl I � / - � � - r,..{ ,..Tf ��:[? =:r_.`-1...'��''J ii.L�.� ��irhpi t Ica'-E f - --- _ -- C)Aj C��t�e►,iG��1.EEe5 -� —_ r �� boaer�,F ���.�'� rTE� �T�+ �14• c'`;E a A�A. 12 ,L.c, . �'E, >✓'ATE �,PP VF-D Ds.TE 1 i a I UNDERGROUND UTILITIES WERE COMPILED FROM AVA ILABLE FVIS: RECORD PLANS OF UTILITY COMPANIES AND PWL#C AGENCIES �/ E N AND ARE APPROXIMATE ONLY. BEFORE DESIGN A140 �S'RUC h TI4N CALL 010 SAFE 1 - 800 - 322 -48 44.. y � r� �, � �/ � /� �;✓1 /a c.i tl..:/ .3/ A'a i^d.s/rirX ^ TTT 0 0 ✓ t r iS l tie- ✓� U I \ E 1 ` 3'' ✓ ° 0 ---- 1 \ ,/ t f l o �C REFERENCES. / I ' 0 / f / q \ 7 �� �"Ppy' { N y I r + hoi ; 1 r , I Its, / x i• � � 1 I ;� r / C � PROJECT TITLE: Ar - LOT 20 E L L I 0 T ROAD r ► / ' CEN TERV I LLE, MA. �/ f // f � l r I O f / ✓ � r PROFESSIONAL LAND RVEYOR DATE h! Mrs g PREPARED FOR: �' DANIEL HOSTETTER PRO SSIONAL ENGINEER—CIVIL DA E n.:* &�8 r ry �, The BSC Group \ �• \ 1 - - f -7- -*.-. , 1• ` i Cape Cod Swrey Cons #s, \ f// JL 3261 Main Street r 1 f f su,�.� \" . '�3 f � / m_ ! Route 6A 1 / *, •` � �� '• r � / � f � � ,� I 02630 Barnstable Village MA 617 362 8133 `o o � 1 ( r F / b I • t C )f / / \ / / `P �r ,,, � 0 �J // Fes-b. -�`la" ,,, „-• ��..J r Ile OFcb 0 SITE PLAN ID NOTES { - I) PROPERTY LINE INFORMATION WAS COMPILED FROM PLAN BOOK 305 PAGES 44 B 45 AND f \ 1 DOES NOT REPRESENT AN ACTUAL SURVEY ON \\ / TE 5"f THE GROUND. \ / /t 2)TOPOGRAPHY PERFORMED BY TRANSIT AND STADIA METHOD. SCALE: 1" = r 20 I o \\ 0 5 10 15 20 30 40 FEET DATE: 1 / 10/85 cn �\ COMP/DESIGN: S.A.H. / G.G.M. CHECK:_ � \ _ / DRAWN G.G.M. — FIELD: G.G.M./ J.V.B. FILE NO: ----- _-_ __ ------------ DWG. NO: 1061 SHEET JOB NO 3-1595-0 I OF 2