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Commonwealth of Massachusetts a?t7U��o2'
�a ,p Title 5 Official Inspection Form f_
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address ,'
Kaitlyn Whidden
Owner Owner's Name /
information is Centerville �(/ Ma 02632 6-17-19
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 forms A. Inspector Information 13 91
on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
VQ Sandwich Ma 02563
City/Town State Zip Code
r r (508)477-0653 S113747
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
Brett Hickey � 're °. "°" a�,.m,�o �.
-17-19
Uzta:10t9.O6.t90i:19:S9OCVO
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 has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit.the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
r '
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
V
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 647-19
required for every
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:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
L�
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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
L
Commonwealth of Massachusetts
�A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
u
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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
El El clogged
of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a 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
11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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
❑ R Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ E Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Fx� Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El 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 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ El 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
1
c°f Commonwealth of Massachusetts
Title 5 Official Inspection Form
I
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r.
43 Elliott Street
V
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ EJ Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ El Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ a 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:
0 ❑ 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
Commonwealth of Massachusetts
�m ,,p Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
10 43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes No
Water meter readings, if available(last 2 years usage(gpd)): See below
Detail:
i
***20,17- 41,000gallons 2018- 48,000gaIIons***
Sump pump? ❑ Yes H No
Last date of occupancy: currentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
,u1
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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: Owner- last pumped 1 year ago
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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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
❑ Tightitank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1995 per plans
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron N 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l;
N
43 Elliott Street
Lr'
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
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
1
Dimensions: 000gallons
7if
Sludge depth:
2911
Distance from top of sludge to bottom of outlet tee or baffle
On
Scum thickness
NS
Distance from top of scum to top of outlet tee or baffle
NS
Distance from bottom of scum to bottom of outlet tee or baffle
measured
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.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
@ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
u
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: NAfeet
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: NA
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
cam, Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M � 43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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):
0"
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.):
The d-box was in working order at the time of inspection.
II
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
e Title 5 Official Inspection Form
+' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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.):
NA
*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):
If SAS not located, explain why:
Type:
0 leaching pits number: (1) 6'x6' pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
i
__ I
cam, Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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.):
The SAS was in working order at the time of inspection. Liquid level in pit was 2' below
invert when viewed (SAS approximately 2/3 full).
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z 43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
. I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
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
4\
1
7
may\
I
t5ins .doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
P P 9 P Y 9
Commonwealth of Massachusetts
�d Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owner's Name
information is Centerville Ma 02632 6-17-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: No GW @ 12'feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
5-12-95
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)
❑ AccessedUSGS database -explain:
I
You must describe how you established the high ground water elevation:
A plan on file at the local Board of Health was used to determine high groundwater.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Elliott Street
Property Address
Kaitlyn Whidden
Owner Owners Name
information is Centerville Ma 02632 6-17-19
required for every
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 br attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
UNITED STATES;`&-}''AEt SWVC ti -lass <..
• Sender: Please print your name, address, and ZIP+4 in this box •
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SENDER: COMPLETETHISSECTION
COMPLETESECTION / DELIVERY
■ Complete items 1,2,and 3.Also complete A. Si 'ature
item a if Restricted Delivery is desired. . ❑Agent'
■ Print your name and address on the reversb ❑Addressee
so that we can return the card to you.. Received by P'nted Nam C. Date of Delivery
■ Attach this card to the back of the mailpiece,
-or on the front if space permits.
1. Article Addressed to: D. Is delivery addre item 1? ❑Yes
If YES,enter eliv b w: ❑No
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3. Service Typ
13 Certified Ma Mail
aCQ oZ ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service label) f z i17006 i 215 0 0 0 2 {1 f4 2 0 0 0 2 r
PS Form 3811,February 2004 Domestic Return Receipt 165s-A2-W1e40',
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Postal Service,.
MAILT. RECEIPT
f1 CERTIFIED
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PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
1
T ' '
HE 1p�
own of Barnstable Barnstable
kwAvA
Regulatory Services Department N�ftwiCeC i
• BARNSfABLE.
MASS. Public Health Division m
PIED Mai A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
July 1, 2008
Jeanne Sanders
43 Elliott Street
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 43 Elliott Street, Centerville, MA was last inspected on
June 20, 2008,by Robert Paolini, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Sandy soil, signs of hydraulic failure. Leach pit was full at the time of the inspection with
stain lines up in risers.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
m s cKean, R.S., CHO
Agent of the Board of Health
CERTIFIED MAIL#7006 2150 0002 1042 0002
Q:\SEPTIC\Letters Septic Inspection Failures\43 Elliott Street.doc
Commonwealth Qf Massachusetts
U W Title 5 Official Insp ection Forme `
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 43 Elliott St.
Property Address
Jeanne Sanders.
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
Inspection results mustlbe submitted on this form. Inspection forms may not be altered in any
way.
Important:
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not use the return Name of Inspector
key. Capewide Enterprises LLC
Company Name
f) IQ I
P- P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
3
I certify that I have personally inspected the sewage disposal system at this address and tfia 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 mAs tenance`of on site
sewage disposal systems. I'am a DEP approved system inspector pursuant to^_ct ion 1 40 gi
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails '
. ca
Needs Further Evaluation by the Local Approving Authority
I
6/20/2008
Inspector's Signature Date
The system inspector shall submit a co of this inspection report to the Approving Authority Board
Y p PY P p pp. 9 Y(
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,060 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.
43 Elliott St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1
'1
Commonwealth cif Massachusetts
W Title 5"Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma.. 02632 6/20/2008
every page. Cityrrown State Zip Code Date of Inspection
I
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:
The leaching Pit is in hydraulic failure.Pit was full at time of inspection.
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.
Answer yes, no or not determined (Y, N, ND) in the ❑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.
ND Explain:
i
❑ 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
❑ obstruction is 'removed
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2
Commonwealth of Massachusetts
W Title 5' 'Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is
required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
i
B. Certification (cont.)
I
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
i
ND Explain:
I
�i
❑ 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
❑ obstruction is removed
ND Explain:
III
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
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*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.
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
i
Commonwealth of Massachusetts
W Title 5 'Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
^M 43.Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville j Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification cont.
C) Further Evaluation isIRequired by the Board of Health (cont.):
❑ 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:
i
_ **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is-equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
II
I
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
dueito 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than!Y2 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.
❑ ® Y P cesspool
An p portion of is within 100 feet of a surface water supply or
P or privy Y
tributary to a surface water supply.
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,
43 Elliott St. "
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (c'ont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
i
❑ ® 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.
i
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
i
❑ ❑ 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
i
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.
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
I
t
Commonwealth of Massachusetts
W Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
i
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
i
® _ ❑ WeIre 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:
I
❑ ® Existing information. For example, a plan at the Board of Health.
i
® ❑ 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)]
i
{
I
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6
Commonwealth of Massachusetts
Title 5 'Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 43 Elliott St.
Property Address
Jeanne Sanders 1
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
I
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
I
Number of current residents: 3
i
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate;sewage system? [if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if last 2 ears usage d unavailable
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
I
Commercial/Industrial Flow Conditions:
Type of Establishment:
j
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
1
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:
Last date of occupancy/use: Date
Other(describe):
i
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
�I
D. System Information (cont.)
General Information
Pumping Records:
Source of information: k
Was system pumped as part of the inspection? ❑ Yes E No
If yes, volume pumped:i, gallons
How was quantity pumped determined?
i
Reason for pumping:
Type of System:
I
® 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.
i
❑ Other(describe):
i
Approximate age of all components, date installed (if known)and source of information:
system installed 1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
1
I
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
I '
Commonwealth of Massachusetts
W Title 5 ,0fficial. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I ,
�M °r 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
i
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 16"
feet
Material of construction''
❑ cast iron ®40 PVC ❑ other(explain):
20'+
Distance from private water supply well or suction line: feet
Comments (on conditio'I of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade:
1'
I
feet
Material of construction:)
i
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
a
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1000 gallon
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
26"
i
4"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
9..
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
43 Elliott St.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
i
Commonwealth of Massachusetts
W Title 5 'Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L ° 43 Elliott St.
GSM
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
I
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.):
Pump septic tank every 2 years.lnlet and outlet tees are•in.place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
i
Material of construction':
i
❑ 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
i
Comments (on pumping'recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
i
i
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
i
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10
' I
Commonwealth of Massachusetts
W Title 5 ,0fficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Elliott St. '
G„M i
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
i
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage intolor out of box, etc.):
Box is Ievel.Box has one;outlet lateral.Evidence of solids carryover.No evidence of leakage into or out
of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
I _
Alarms in working order: i ❑ Yes ❑ No.
i
i
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11
i
Commonwealth of Massachusetts
W Title 5 ,Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
° M 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
i.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-1000 gallonw/2' stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
i
❑ 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.): -
Sandy soil.Signs of hydraulic failure.Pit was full at time of,inspection with stain lines up in risers.
i
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
W Title 5 ,Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
I
D. System Information (cont.)
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
I ,
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.):
� I
i
Ili
Privy(locate on site plan):
Materials of construction
I
Dimensions
I
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1
II
43 Elliott St.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
i
i
Map, Page 1 of 2
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http://www.town.bamstable.ma.us/arelims/appgeoapp/map-aspx?propertyID=230121&map... 6/21/2008
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
qM 43 Elliott St.
Property Address
Jeanne Sanders
Owner Owner's Name
information is required for Centerville Ma. 02632 6/20/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i
Site Exam:
I
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Bottom of LP 30'
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:
As-Built Card
• j
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations. i
j
I
i
43 Elliott St.•03/08 G Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Regulatory Services
swxrrsreB
Thomas F. Geiler,.Director
ArEo ,�a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This system septic s
p y m inspection report was completed
p p p d by a private inspector who is certified b
the State of Massachusetts, y Department
ment of Environmenta
l al Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations
p s contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit'..
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the'iinspection.
Q:ISEPTICIDisclaimer Private Septic Inspections.DOC
Town of'Barnstable Barnstable
Regulatory Services Department NAmmedca city1
>+BARN16 9. �� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CE
rson TRS.
A 02632
St.
FINAL ORDER
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at, 43 Elliott Street, Centerville, MA was last inspected on
6/20/2008, by Robert Paolini, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system Failed under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Sandy soil, signs of hydraulic failure, pit was full at time of inspection with stain
lines up in risers."
The deadline for repair h L We, The Department of the Board of Health, have not
been informed that you have taken any steps to bring your failed system into compliance.
Therefore, you are ordered to repair or replace the septic system within 60 days from the
date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter,within seven (7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOA OF HEALTH
Thomas McKean, R.S., CHO Agent of the Board of Health (( Fly
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Town of Barnstable Barnstable
Regulatory Services Department 1edcacffv KAMLC
Public Health Division m
ror 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
'C12-5
9/04/09
J me S ders
43 li t St.w rent le,.MA. 02632 _ . . ��( c4, /0c -It
FINAL ORDER
I
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at, 43 Elliott Street, Centerville, MA was last inspected on
6/20/2008,by Robert Paolini, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
"Sandy soil, signs of hydraulic failure, pit was full at time of inspection with stain
lines up in risers."
The deadline,for repair ha past We, The Department of the Board of Health, have not
been informed that you have t en any steps to bring your failed system into compliance.
Therefore, you are ordered to repair or replace the septic system within 60 days from the
date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter, within seven (7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF' BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health
�.. -...... _ _ __- _. ____ -�-- L- .
l�,.t G��—�. Gam- 2.�ca.R,
�� �2
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,.
Town of Barnstable Barnstable
Y
Regulatory Services Department Mftedcap j
BARNSTABLF.
1 59. ,$�' Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
08/07/09
Jeanne Sanders
43 Elliott St.
Centerville, MA �c �O ply
FINAL ORDER
ORDER TO'COMPLY WITH:STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at, 43 Elliott Street, Centerville, MA was last inspected on
6/20/2008,by Robert Paolini, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
"Sandy soil, signs of hydraulic failure, pit was full at time of inspection with stain
lines up in risers."
The deadline for repair has past. We, The Department of the Board of Health, have not
been informed that you have taken any steps to bring your failed system into compliance.
Therefore, you are ordered to repair or replace the septic system within 60 days from the
date you receive this notification.
You may request a hearing before the Board of Health, a written petition requesting a
hearing on the matter, within seven(7) days after the day this order was received.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PE;OEIR OF T E BOARD OF HEALTH
cean, R.S:;>CHO
Agent of the Board of Health
_��............ Fps.....7� ..._
THE COMMONWEALTH OF,MASSACH?SETTS
F
............................
°\' App iration for Dispaii al Works Tonstrurtiura Vamit
Application is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal
Y
st
a . s�l ! _ e� �!` �� mil-'
........ ._._ �• -----------------------------------•--------
.... ... . ... ..
ot
catioxyy r�SsY .. I... No.
Owne �}
..--mi Y. ..ss
- /GCS
�
Installer Address )
U Type of Building Size Lot_ _ _ ___ _____Sq. fe t
1_9
Dwelling—No. of Bedrooms.......... --------------------------Expansion Attic ( ) Gakage Grinder ��
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Oth r fi res ..-----••---------------•-------•--•-
W Design Flow........ . . .................... gallons per per=per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity. allons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—N .................... 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.......................................
.l
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------------_........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................•.. Depth to ground w ter--------------- .......
W ------------------------------------
-------
•--------------------
---------
----------------
•-----------
----
•---------
•-------
-- ----------- ---------------
O Description of Soil...........................................................................
U ---•-------------------------------------••---------•--------------•--•-----------•-----------------•------W
V 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 l"IT rIS^
;.: IL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ss ed by t of hea h.
Signed. ... ............. ....•.... .. .................. ` 7
Appli tion Approved By ;i� � �y .
�' -_.._. .•-------•-.... '
ate
Application Disapproved for the following reaso .---••--•------••-•--•-•--•••--.
r
--......--•---•------•--......--•----------------•--••-••-•--•-•--...-- -----------------------------•-------------- --------------------------------------------------------------
Datc
Permit No._�3 .�---------•-------------------- Issued........................................... ate.
Date
Ny'V
o......... .............. Fes$..... ...
THE COMMONWEALTH OF MASSACHUSETTS
B'OAR F f!�-IjE TI-�(IJ
.........OF....... .......�!.'`-✓.. .. -__
I r Alip irFatilan for Bis�vii ai Works Toaastrurtion Prrmit
Application is hereby made for a 11 Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
c 'System a -� `- --------------------------------------------
J�OcatiO/� r s i•�' .........................................
or....
Lot :�i O.
R===X f
Owner Address
W _
Installer� Address i'• (')
Type of Building Size Lot. __ .._ .._..Sq. fe t
,.� Dwelling—No. of Bedrooms.......... --------------------------Expansion Attic ( ) Ga>�age Grinder ��
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Othr fi res . 0-------------------------------------------------- ------ ---------------------••------•----
W Design Flow_._..... .�. .................... .gallons per it per day. Total daily flow_.__.._.._.............__................_._gallons.
WSeptic Tank—Liquid capacity-Gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......._____.__.__.__sq. ft.
Seepage Pit NO........I----------- Diameter.................... Depth below inlet.................... Total leaching area........._.......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........'----------------------
--------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------ ----------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..------------- ---___--
a -•--••----•------------------•-""•"-"-""-"-""-"-"-----"-""""-•-•--""--"--"""---""---.............--•"-------"•"""""-•"-"-""""
Descriptionof Soil-................................................................------ ------- ------------ . ".•. . . .-•.
�., --------------------------------------------------------------------------------------"----------- I�'J -.� 1, - f
--"""
--------------------------------------•-•----------•-------------------------------------------------------------"-•---------•-• •"••---•--------"--"-- ---------------- ........................
V 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'TT .,
p of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed------ ' -"--"""•-•-----....-"
....--
Application .....
� De-
Approved B ;' VPP Y z `'' lI�Application Disapproved for the following reaso ---"-----••--------"-"---""-----"-"---•------""--•--"•------""----"-•---"•"--------"-------"•-""""__.....---
-•------------------------------------------ --------------------------------------------------------------
�'l1 Date
Permit No. ..V/.(6J-�------5---"""....------ Issued---------------------------------------"---------------
D
THE COMMONWEALTH OF MASSACHUSETTS
WAOARDf.0F......... ....., 1....�...�..�? .....
(Irr#if irFatr of MalutpfiFatirr X
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
bY•"•""""••-""-"-"""".................."---"""•"-...--•--"-"......_._."""---"-•............"----------"-------•...._....__...•-•"""..........-"-"-"-""••-•=_.---
has been installed in accord nce with the provisions of i T . 5 f�e�ate Sanitary Code as desc -n the
application for Disposal Works Construction Permit No. _��_ _--,)------- dated_...._ I/t.�.1..__---__--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................ ......................... Inspector.............................
D--------------_.__.....------...........
THE COMMONWEALTH OF MASSACHUSETTS
!� BOA O E L�H
; 0 L C__ 1-71
NO... �.. !.-.•- 1��ff...... _
-^_._ FEE.......it," .....
Diapaout Norkii Toaio#r ilan rruti#
Permissioni hereby granted...................................................................................................................... ........_....---•-•...
to Construct or pair a}n Individual S w.a po tem -7.—
at No.-" 1 •-
Street ( /
as shown on the applicat• n for Disposal Works Construction Per o..?------�; ate ./-� _.�._. '.�kV.... - '.....-
� Board of Heath
DATE.......-- -"-----". ... ----"-"-""----------•"---•----"-"-"-"""- --
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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