HomeMy WebLinkAbout0099 EMERSON WAY - Health 99 Emerson Way ,
Centerville P
A = 189 105
UPC 12543
No.53LOR_
HASTINGS,hIN
II
. t8q - io5
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ , 99 Emerson Way .
V
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
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.
Imng out forms
A. Inspector Information
filling out forms
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
..... ........ ... _......_.
52 Rivers End Road
Company Address
Teaticket Ma. 02536
City/Town State Zip Code
508-280-3356 S13938
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
03/30/2021 `a -
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Citylrown 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:
This 4 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding two precast
leaching pits with stone. At the time of the inspection no visible failure criteria was found. Please read
the bottom of the first page of this report. This statement is from the Ma. DEP. This home was
inspected under the Ma. DEP and The Town of Barnstable guidelines.
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
i
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
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
` 99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown 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
than '/2 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 .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 9EmersonW� 9ay
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ 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
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): town water
Detail:
In 2020 -82,000 gallons were used and in 2019- 102,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown 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:
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 01 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
�n
99 Emerson Way
L-
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is Centerville MA 02632 03/30/2021
required for every
page. City(rown 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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 13"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/`
� � 99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is Centerville MA 02632 03/30/2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 5"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:
H-10 1000 gallon
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
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 recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the baffle was in place.
I
l5insp.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
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Citylrown 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: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�n
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ 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.7/2 612 0 1 8 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
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
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.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityfrown 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
V
D
{
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
0 Title 5 Official Inspection Form
1% Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
page. Cityrrown 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: 13 plus feetfeet
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 augered a hole at a lower elevation and shot it with a transit tp show 4 plus feet of seperation.
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
i
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
99 Emerson Way
Property Address
Jeffrey Zent& Lisa Milau-Zent
Owner Owner's Name
information is required for every Centerville MA 02632 03/30/2021
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
V Sv�v
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART AAl
CERTIFICATION
Property Address: �wt rS0�1
_ A
Owner's Name:
Owner's Address:
Date of Inspection.:
Name of Inspector: leas print)
Company Name: ` n S�C `
Mailing Address: Af
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
C= c)
Passes
Conditionally Passes
Needs Further Evaluation by the Local.Approving AuthoF
E�
F ils o c:t
Inspector's Signature: Date: ��a>ht "'
=a �
The system inspector shall submit a copy of this.inspection report to the Approving Authority(Board o Health
41
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flo of 10,09
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o ce of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address}tow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ibls'o _
Owner: PIG/uq _
Date of Inspection:
Inspection Summary: Check A,B;C,D or E/ALWAYS complete all of Section D
A. /System Passes:
ICI I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Co tional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or pair,as approved by the Board of Health,will pass.
]9
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 ars old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a compl ' g septic tank as approved by the Board of Health.
*A metal septic tank will pass inspe on if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less tha 0 years old is available.
ND explain:
Observation of se ge backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or du to a broken,settled or uneven distribution box. System will pass inspection if(with,
approval of Board of ealth):
broken pipe(s)awe mplaced
obstruction is removed
distribution.box is.leveled or replaced
ND explain:
Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass ins ction if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
per+ CERTIFICATION(continued)
Property Address: wag
C� Sri u
Owner:—Picr6wot
Date of Inspection:
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.
I. System will pass unless Board of Health determines in accorda a with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect pu tc health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface wate
— Cesspool or privy is within 50 feet of a bordering egetated wetland or a salt marsh
2. System will fail unless the Board of He th(and Public Water Supplier,if any)determines that the
system is functioning in a manner that p tects the public health,safety and environment:
_ The system has a septic tank d soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary a surface water supply.
— The system has a septic and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a se c tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has eptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply ell**. Method used to determine distance
**This system p ses if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and vo the organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure crite a are triggered.A copy of the analysis must be attached to this form.
3. O 'er:
I
3
Page 4 of 11
OFFICIAL:.INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE I)SPO.SAUSYSTEM INSPECTION FORM
PART:A-
CERTIFICATION(continued)
Property Address:
f T
Owner: OF --
Date of Inspection:
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 Y2 day flow
—42( 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 coliform bacteria and volatile organic_compounds
indicates that the well is free from pollution from that facility 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.]
y�//"O(Yes/No)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 mus rve-a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"t ch of the following:
(The following criteria apply to lar ystems in.addition to the criteria above)
yes no
the system is w' ' 400 feet of a surface drinking water supply
the syste is within 200 feet of a tributary to a surface drinking water supply
_ the stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Z e H of a public water supply well
If you h e answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" ' Section D above the large system has failed. The owner or operator of any large system considered a.
si ' cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15. 04.The system owner should contact the appropriate regional office of the Department.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST"
Property Address: �Gl/f�Pi1S
d
Owner 41)01-K
Date of Inspection: 06
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
C 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?
U� 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:
Yes no
_ 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(3)(b))
5
Page 6 of i l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: P)ot k N4& _
Date of Inspection: pg
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): y Number of bedrooms(actual): T
DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: /
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no): AV[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: -1s evc�
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank pres yes or no):_
Non-sanitary waste discharge o the Title 5 system(yes or no):
Water meter readings,if tlable:
Last date of occupant se:
OTHER(desc ' e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no):jqP
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)
_Tight tank —Attach a copy of the DEP approval
_Other(describe):
Approximate age of al components,date installed(if known)and source of information:
k 6&2 zk o
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: N
Owner:
Date of Inspection: q v7
BUILDING SEWER(locate on site plan)
n
Depth below grade: /6
Materials of construction:_cast iron j( 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: sr concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ IS age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:. �I t a
Distance from top of sludge to bottom of outlet tee or baffle: 6) 7
Scum thickness:
Distance from top of scum to top of outlet tee or baffle' 7 a
Distance from bottom of scum to bottom of outlet tee or�*ffle:
How were dimensions determined: egSUrrU
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to utlet invert evidence of leakage; te.):
j eae urX i *ee.)
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:`concrete_metal fi glass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outl tee or baffle:
Distance from bottom of scum to bott of outlet tee or baffle:
Date of last pumping:
Comments(on pumping reco dations, inlet and outlet tee or baffle condition;structural integrity, liquid levels
as related to outlet invert,evid ce of leakage,etc.):
7
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: e
Owner: ot-p �—
4�bv
Date of Inspection:
TIGHT or HOLDING TANK; (tank must be purr at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete me fiberglass_polyethylene other(explain):
Dimensions:
Capacity: pa ns
Design Flow: alIons/day
Alarm present(yes or no):
Alarm level: Al in working order(yes or no):
Date of last pumping:
Comments(condition alarm and float switches,etc.):
DISTRIBUTION BOX: QV (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 'evgo
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage intg or out of box,etc.):
� or
r
PUMP CHAMBER: (locate on site plan
Pumps in working order(yes or no):.
AIarms in working order(yes or no .
Comments(note condition of p p chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: M{ . p
'w• '
Owner: 3rK,0MjMV'
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
— -leaching pits,number: 6Z
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number;dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,)evel of ponding,damp soil,f condition of vegetation,
etc.):
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configurationWe
Depth—top of Iiquid to inl
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater
Comments(note conditioulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note conditi of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
9
i
Page 10 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Adrdre�ss Q �( �R $0h
w
Owner:
'�vl V 6 P.
Date of Inspection: 01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
D
3
Page 1 I of I 1
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: �.Vt7Y trw
Date of Inspection:°rem
SITE EXAM
Slope
Surface water V00
Check cellar 4?,eS
Shallow wells l)d
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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 big ground water elev tion:
-- U� . s
Il
COMMONWEALTH OF MASSACHUSETTS
z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
+ d DEPARTMENT OF ENVIRONMENTAL PR
RECEIVED
o m�
I y
O,'M Sve
350 MAIN STREET MAY 18 2004
WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
CER HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS p
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM TAP
PART A PARCEL ;
CERTIFICATION -
MAP 189 PAR 105 ()T 4-c y
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner's Name: HAGON,DARLENE
Owner's Address: 19 BILLINGTON LANE
BREWSTER,MA 02631
Date of Inspection APRIL 29,2004
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the infonnation reported
below is true,accurate and complete as of the time of the inspection. The inspection was perfonned based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all.of Section D
A. System Passes: ✓
l have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
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 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:
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
distribution box is leveled or replaced
ND explain:
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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
C. Further Evaluation is Required by the Board of Health: N/A
_ 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 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 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 public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
D. System Failure Criteria applicable to all systems: N/A
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 pits is less than 6"below invert or available volume is less than'/2 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this fonn.)
NO (Yes/No)The system fails. I have detennined 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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation 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 nonnal 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 scorn
✓ Was the facility owner(and occupants if different from owner)provided with infonnation on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing infonnation. 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(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2002 68,000/2003 59,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infornation: N/A
Was system pumped as part of the inspection(yes or no): 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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1988
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 6"
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 9"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to the bottom of outlet tee or baffle: 27"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions detennined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE.NO SIGN OF OVERLOADING OR
LEAKAGE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
TIGHT or HOLDING TANK: N/A (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/day
Alann present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alann and float switches,etc.):
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.,):
DISTRIBUTION BOX IS 12"xl6", 15"BELOW GRADE.ONE LINE IN,TWO LINES OUT.BOX IS CLEAN
AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarns in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
i
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 6'x8' BLOCK POOL AND ONE 1,000 GALLON PRE CAST PIT. BOTH COVERS 6"
BELOW GRADE.20"WATER.STAIN LINES AT 24"AND 28".NO SIGN OF OVERLOADING OR SOLID
CARRYOVER.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 10 01'1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I
i
1 / �
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i
0
Title 5 Inspection Form 6/15/2000 10
Page I 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 EMERSON WAY
CENTERVILLE,MA 02632
Owner: HAGON,DARLENE
Date of Inspection: APRIL 29,2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 10 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-lf checked.date of design plan reviewed:
Observation 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:
TEST HOLE 10' NO WATER. BOTTOM OF PIT 3'6"ABOVE TEST HOLE.
Y
Title 5 Inspection Form 6/15/2000 11
R
' =' • � TOWN OF BARNSTABLE /
I 15
LOCATION �Jq E 46*6a.J SEWAGE # F?-( YYA
VILLAGE ASSESSOR'S MAP & LOT/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /0 00 65T _!
LEACHING FACILITY:(type)_ (size) 2 .
yNO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:_--JD-7 O ki
DATE COUPLIANCE ISSUED.
VARIANCE GRANTED: Yes �No ✓ _
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56
TOWN OF BARNSTABLE
LOCATION £� £���N /��` SEWAGE #
VILLAGE C. /+✓!
ASSESSORS MAP 6t LOT
/,v5Af�/?_s
INS R'S NAME 6t PHONE NO.. A & B CANCO 775-6264
SEPTIC TANK CAPACITY .S f'.Ig /�
LEACHING FACILITY:(type) - (size)
NQ OFBE ROOMS - 'PRIVATE WELL OR PUBLIC WATER
-,.
BUILDER OR OWNER
iNSP£G�a
DATE s d
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
. P
P
No.... Fim.... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF..... ....................................
Appliration for DW.VaDal Warks (foutitrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair A,-)"an Individual Sewage Disposal
System at:
...........0(--'1--- ----- ........................ ..................................................................................................
Location-Address or Lot No.
.............. ..................................... .................................................................................................
01wr Add,...................... ... . ...... .. ..
......8-PikO.- 12M...A .........................................
Installer Address
Type of Building Size Lot....................--------Sq. feet
Dwelling—No. of Bedrooms................... .......................Expansion Attic Garbage Grinder ( )
Other—Type of Building -------------------------_ No. of persons.....--..............------. Showers Cafeteria ( )
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth.....--.........
Disposal Trench—No..................... Width._...........--..... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter.................... Depth below inlet........_........._. Total leaching area............--....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit--..--............._ Depth to ground water....------...........--.
Test Pit No. 2................minutes per inch Depth of Test Pit...--..._....---_-.. Depth to ground water.-.---.--_-------------
--------•----------------------------------------•---------------------......._....•--•••-...._..-•-.........................................................
0 Description of Soil------------------------------------------------.......................................................................................................................
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
..................................................................................................... j .........................................................................V
U Nature of Repairs or Alterations—Answer when applicable..... ; 0----RF.....0-----/900----6.4,!o.-----_-_-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TTLE 5 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 Vlth.
Signed--------- ..... . . ......CT. . . ......... ..................... ...
Date
It 4 ....................... ^U. t Application Approved By.............6-0�. ...1!4a - - ------------------- ......... _':
Date
Application Disapproved for the following reasons:..............................................................................................................
.....................................................................................................................................................................................................
Date
Permit No....._ ------------------------- Issued-----------------------------------
Date 4
Z: f. L
kNo.... Fss....
t
j� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... " - --_------------------OF.............. ------------. ..... -
Appliratiou for UiipnsFal Works C> owitratr#inat Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
:. .O.Q.N..... ..y-----------------•------ --•-------•-•.........._..............-----•--------•-----
1 _ Location-Address C� or Lot No.
r✓i,�.>�.�:/.LLI..:_..%��fir===--=-
j Owner. Address 1
-------•---•------------ {�E 1� :.__! !�; /�1!. .................. < r lc✓,,t_..h3� �?Y...���5..----------........_.....----------
I Installer Address
Type of Building Size Lot......_---------------------Sq. feet
�-, Dwelling—No. of Bedrooms................... ..................... Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures ------------------------------•. .
Q ------------------------------
---------------------------
W Design Flow............................................gallons per person per day. Total daily flow._..._.__..-_._.............._.__...__.__...gallons.
Ga Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------......minutes per inch Depth of Test Pit____________________ Depth to ground water_--___-__---____•--_-._-
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..___-_--____-_-___-_-..
P4 •-•-----•••------------•----•••••-••••-••-••••••-•--•••---•-••••••••..............••----------------.......
---------•-------------.........................
X
U --•--------------------------------------•----•----•---------------------------------------------.....----------•------•-------•---------------•-------------------------------------••----....--•-----
W
V Nature of Repairs or Alterations—Answer when applicable.-_-__A.! a,,,l_ _-._o lr-------:0...... .................
• ••••• • ----- •-••-••••••-------•••••-•--••••••••--••••---•••••--••-------------•••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of"TILE 5 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...................................................................................... 1r 2G fe
Date
Application Approved By... � -
---- -- ---�-�•-------•--------------
Date
Application Disapproved for the following reasons_________________________________________________________________________________________________________________
--------------•---------......----•-•--------•-------------•--•-•---------------.....------•--•---------•----••-•-••--•-••••••---••-•-••-•-••--•-••-•-•••-----------••--•••-••--------•-••-••-•--•-----
Date
PermitNo------2-`4 == -------------------------- Issued---____-•------------------------------_-_--------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. ......OF...............� ...............................
Tertif irate of ToutpliFaat r
THIS IS TO CERTIFY, That the Individual Sewage Disposal System'}constructed ( ) or Repaired (N}
by---------------------- �� �_------� ::..._ = ---------------•••----n------------------------------___-----..1\..-----..............-------..._...._..._...---------------
Installer
at tn... rc ....{{ �'= --------•----------------
has been.installed in accordance with the provis�ibns of T ITi.E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...._ '___ ___L/A..._......... dated--------------------------......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................�.a- = .............................. Inspector........................
.............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;r 1.� .4"!r.� ...........OF.. ._. �`;. f,: _i.,.. r.�lt °�.........................
No..f u—=�f••rt_ FEE...,7
11ispos al Works Tuaatstrar$Uaat :permit
Permission is hereby ranted.............� p_cz=e............ r
to Construct ( ) or Repair �,� an Individual Sewage Disposal System
- ...............U------------- -- ----------•---------------------
Street
as shown on the application for Disposal Works Construction Permit No�'�=la��.__ Dated..........................................
I ....................................
1 DATE.......... -=-....----`�----...-•--------------- -------- Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
1