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HomeMy WebLinkAbout0129 EMERSON WAY - Health 129 Emerson Way Centerville P A = 189 127 Owiford, NO. 152 1/3 ORA 10% o s s - _ --- ��.u�.. a :�.....s� „'.....tea-..�:,,.;.�.�w^ --"'..•,�•.+,r., _ - _ - �....._�.r+r*.w-_��_ _ ,-,u. __- .,.,> .- C) Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 129 Emerson Way / Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 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. A. General Information 1. Inspector: , Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper functign;and maintgnanceiof on site ...R!E sewage disposal systems. I am a DEP approved system inspector purlsuant to Seotion:1-.340 of Title 5 310 CMR 15.000 The system: '"`" . ® Passes ❑ Conditionally Passes ❑ Falls , ❑ Needs Further Evaluation by the Local Approving Authority` VIM 5-3-12 "S'' Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ti t5ins•11/10 TitlWlnsp,�b.n rm:Subsurface Sewage 2)posal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes- ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Boarcl of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y N ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page:2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): r C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy Is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•'11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a-septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 99 . p ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page:4 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ®' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ -® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes".or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 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) ® ❑ 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins-I IMO Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4-2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310.CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft:, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins^11/10 .Trde.5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner— not pumped since new in 2007 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a co of the current operation and 9Y PY P maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12"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: 1500 gal Sludge depth: 12" t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Ownrer Owner's Name information is required for every Centerville MA 02632 5-3-12 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins:•11110 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur owner Owner's Name nformavquiretifo is Centerville MA 02632 5-3-12 �equired for every )age. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I Soil Absorption System SAS locate on site Ian, excavation not required): P Y ( ) ( P If SAS not located, explain why: t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 129 Emerson Wa y Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ' Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator leach field in good condition with no sign of back-up into d-box or surrounding stone. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids.layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 1 Commonwealth of Massachusetts 'r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way _ Property Address Lisa Arthur _ )caner Owner's Name formation is equired for every Centerville MA 02632 5-3-12 iage. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 vegetatioin, etc.): Sins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 ol.f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 Emerson Way Property Address Lisa Arthur Owrner Owner's Name information is required for every Centerville MA 02632 5-3-12 pages. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties t 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 /I I !7 ' ' ok A, • 1 D 38' 13 c- 3 . A 1_26' f-0- 1-6, F t5ims•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 1 i Commonwealth of Massachusetts Title 5 Official Inspection` Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 129 Emerson Way Property Address Lisa Arthur ner Owner's Name ormation is fo quired for every Centerville MA 02632 5-3-12 ge. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked date of P design Ian 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 51ns•11110 Titie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Emerson Way Property Address Lisa Arthur Owner Owner's Name information is required for every Centerville MA 02632 5-3-12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 1 TOWN OF BARNSTABLE LOCATION /a 9 //tC v�►e�/sue f'i✓u�' SEWAGE # --- - VII:LAGE 2a1TCl y �l ASSESSOR'S MAP&LOT . INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY -SV0 LEACHING-FACILITY: (type) �� F� �/ ��DYs (size) 7 NO.OF BEDROOMS 3 —-- tUILDER OR OWNER PERMITDATE: _ COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. ----v Feet Private Water Supply Well and Leaching Facility (If any wills exist-- on site or vANn 200 t of leaching facility) . , ]Feet f Edge of Wetland and Leaching Facility(If any wetlands exist r-t:i within 300 feet 9f leaching facility) Feet Furnished by � �W✓/ /u� 1� ��� ��` A -D-06' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION , � Syev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / -'/o?7 Property Address: 129 Emerson Way Centerville MA r Owner's Name: Joseph Miele `. Owner's Address: 26'Leitha Drive Waltham MA 02451 r, Date of Inspection: April 5,2007 Job#07-77 - Cn Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. =X cn Mailing Address: 189 CAMMETT ROAD MARSTONS 1VIILLS MA 02648, Telephone Number: 508-428-1779 rn Y 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: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local A roving Authority Fails Inspector's Signature. Date: 4/5/07 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the,appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Infiltrators have no standing water and no evidence of surcharge,recommend pumping tank. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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: 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 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 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank.and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5;2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool . _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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.] _No_(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 must serve 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 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. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant, or Board of Health _X_ Were any of the system components pumped out in the previous two weeks ? _X_ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection`? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site _X_ _ 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? _X _ 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 _X_ _ Existing information. For example,a plan at the Board of Health. X _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 0 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 100,000 gal.=136 gpd. Sump pump(yes or no): No Last date of occupancy: One month prior to inspection. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: None Source of information: Owner 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 _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_X_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: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_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: 10.5'long x 5.8'wide— 1500 gal. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level is at bottom of outlet invert.Recommend pumping tank. GREASE TRAP: No (locate on site plan) 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.): it • 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: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 TIGHT or HOLDING TANK: No (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 Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): Trace of solids,no high stains.Liquid level at bottom of both outlet wipes. PUMP CHAMBER: • No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number: _X_leaching chambers,number: Infiltrators leaching galleries,number: _leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Infiltrators were empty at time of inspection with no evidence of surcharge. CESSPOOLS: No (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: No (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.): • Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 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. Emerson Way Water Service .......................... .:... i:::1 X ...... ... . ...... ................. ........................... ............. ............................ ........... ........ ....... ........... ................................. ..... .. ............. ............................... .................. .. ...................................... ........................ .. ............ ........ ..... ........... . ......... .. .. ........ . .... ... .......................... .. .... .................. 26 38 50 32 • Page 1 I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 129 Emerson Way,Centerville Owner: Joseph Miele Date of Inspection: April 5,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 15 and topo map shows property above el.40. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a a DEPARTMENT OF ENVIRONMENTAL PROT N RC(., SEP 12 2002 rown,c HEAL?H F;,'-'1 `E . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �t 4 i CERTIFICATION I Property Address: a WkJk4A Owner's NamAZaq MAP Owner's Address: 9, P,12,94k�� PARCEL ; 2.1 Date of Inspection: o a LOT Name of Inspecto (plea a print) Company Nam Mailing Address: o p 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: Passes Conditionally Passes eeds Further Evaluation by the Local Approving Authority ��(ails Ins ector's Signature: Date: P The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection..If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. 16L�Notes and Comments� � 0 ****This�re.portonly 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 6/15/20.00 page I t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owne Date of Inspection: 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'IO.CMR 15.304 exist.Any failure criteria.not evaluated_ are indicated below. y Comments �' . B. System Conditionally Passes: One or more system components as described in the"Conditional Pass section need to be replaced or repaired.The system,upon completion of the replacement or repair; as approved by the Board of Health,Will pass. 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: 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: 2 Page 3 of 11 . OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: • oh���p rrC�� Owner: 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. 1. System will pass unless Board of Health determines.in accordance with 310 CMR 15303(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 Z. 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 rank and SAS and the SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well- - The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water.supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria and volatile.organic compounds indicates that the well is free from pollution from that facility and the presence of•ainmonia 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: 3 T � Page 4 of 1 l OFFICIAL INSPECTION FORM—.NOT FOR V LUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C/ Owne 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 J 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 '/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 10.0 feet of.a surface water supply,or tributary to a surface _ �U/ water supply. Any portion of a cesspool or privy is within a Zone 1 of a:public well. _ b Any portion of a cesspool or privy is within 50 feet of d 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 facilityand 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CNIR 15:303,therefore the system fails.The system owner-should contact the Board of Health to determine what will be necessary to correct`the failure. E. Large Systems: To be considered a large system the-system must serve a facility with a design now 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 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: (%nmae� Owner: /2 2 Date of Inspection:� �pf� , 0 j 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 —�Zwere.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? _V�_ 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)J 5 r Page 6 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 09 CS2102,f L-- Owne . Date of Inspection: zoo 0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): ;�J Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): :!5 Number of current residents: c` _ Does residence have a garbage grinder(yes or no)�®— Is laundry on a separate sewage system(yes or nqj�[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)): ®a`�L�iO d�- � � Sump pump{yes or no �� ✓�2�'�G1(?P/3Gt� Last date of occupancy: COM.MERCIAL/INDUSTRIAL`,� Type of establishment:. . Design flow(Based on 310 CMR 15.203): . gpd 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 information: 1VU Was system pumped as.part of the inspection(yes or no . If yes, volume pumped: gallons'--How was quantity pumped determined? _ .Reason for.pumping: TYF�F SYSTEM _V 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): proximate'.age of all compo�nts, ate-installed(if o n)and source of information-: e`sewage odors detected when arriving at the site es or no Were s � g (Y ) ,_j66­ 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM..INFORMATION(continued) Property Address: e4 Owne Date of Inspection: 1)00 a BUILDING SEWER(locate on site plan)— Depth below.grade: 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.): M SEPTIC TANK: l/(locate on site plan) c=�� I' Depth below grade: /`�3 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: 0. S `X�P' k 5 Sludge depth: /(o Distance from top of sludge to bottom of outlet tee.or baffle: 7,Z Scum thickness: / 'Distance from top of scum to top of outlet tee or baffle: / el' lat - 1, Distance from bottom of'scum to bottom f outlet tee or baffle: Z. How were dimensions determine A Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels ,-�s related to uutletinvert,e idence of leaka e,etc.)- �' J .i GREASE TRAt;/Jklocate on site plan) 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: Date of Inspection: i TIGHT or HOLDING TANK:24 (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 Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: .Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:jZ(if present must be'opened)(locate on site-plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kage into or out of box, ete .C+irrZ - PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in:working order(yes or no): , Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z G�✓ Owner. Date of Inspection: _P,00p/yj `� (j a SOIL.ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required' If SAS not located explain why: Type ` leaching pits,number:leaching chambers,number:_ eaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc. CESSPOOL -(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: -(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.): 9 Page ]0 of 11 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: Owne Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or water supply enters the building. a benchmarks.Locate all wells within 100 feet.Locate where publicpp y L 9 L 0/_ o INVa 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: long 2C2e.1 Owne n Date of Inspection: %,cOoZ SITE EXAM Slope Surface water Check cellar Shallow wells 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 bf SAS) Checked with local Board of Health-explain: —�hecked with.local.excavators, installers-(attach documentation). V Accessed USGS database-explain: You must describe how you established the high ground water elevation C 11 Permit,Number: Date: Completed by: H`IC., C ;O•UND-W_4.T,E•R LEVEL C.OMPU T A T ION Site Location: Z l �i ��i �f I�''Q �e/%I �Ua/ Lot `:o.. Owner: Address-- Contractor: Address: �:�1� Notes:. �l�/'✓7�' 's ����� ST:G'. 1 . Measure depth ao•water tab[a 0 to nearest.1.I 0-'-*' ._. ... ............ Date _....-.._... month/day/year I S-1 2 Using.Water-Le.vel.Range Zone i and Index WellzNl:ap-locate site an.d'deLermine: � Z OAppr-o.priate.index w.ell........_......................................_...... �. 45) vWater-level-range zone-_..........'_....._........_.._... � S:;EFt.: Using•montnly.rapar.-4,: Currant Water Resources-Conditions" determine current-de th-to l water.level for'indez wel-I ��foz � J month/y=zr S.T•EP Using. e I abrie.oe_Water] Y:._l Adjt_stmen.ts .or index WeII (STEP 2,,Q_cument depth• to weter'•Ievel ioa index well (STEP 3)., and water-level zone (STEP•28) �' 1 determine,water-level adjus.tmertt ................................ .......... STaP- 5 Estimate depth to'hiah water by subt,actine the water-• level adjus?man.t_(STEP 4-`) from measu.red-depth to.water 7 level•at sie.(ST'EP'1) --.._......... -..._........:....................................................................,.. r i 1Ci�iv• jJ:-^.-�.lv�i'.�ivuv�� 'vvil)'�7i.114ili7ii I��LTI: � '� �M�- . �. �\�.w'`�.ta n� :b,,,,�,,,i ��..._._.... --- —.—y--�—m--- �. �� '� ��... w, a� . , e. �� ��.� � � �� s� �.. �. �y � � ��„ { � �� TOWN OF BARNSTABLE LQCATION � Caer5oO) k2cV, VV-.,LAGE DUI ASSESSOR'S MAP&PARCEL I4&TA4.+�NAME&PHONE NO. 'r SEPTIC TANK CAPACITY /SOO LEACHING FACILITY:(type) J`l trc,hofs (size) NO.OF BEDROOMS 3 OWNER J05�'?k 2 PERMIT DATE: C@*ff'L�E DATE: C>'� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Water Service , 38 50 26 3 No.- ` '` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mioponl *pgtem Construction Permit Application for a Permit to Construct( )Repair(r)Upgrade( )Abandon( ) IF Complete System ❑Individual Components Location Address or Lot No. D ZQ 4(g��4 � 1/ Owner's Nam7ee,Address and Te.No. Assessor's Map/Parcel ! / Gi /0 (� j -a Z97 Installer's Name,Add re and T 1.No. Designer's Name,Address and Tel.No. 7VIfff Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(4-310 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Q Type of S.A.S. y— 1f% o <, Description of Soil Nature of Repairs or Alterations(Answer when applicable) �� e /e�e1/" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s o of lth. Signed Date IdA/, Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued �� TOWN OF BARNSTABLE LOCATION Z i C'/�5c�� L�Ja // SEWAGE # VILLAGE C L`' /14'/11am' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY — /,j OU l" L LEACHING FACILITY: (type)?,,,"P�,ri�(��_ (size)11'>e 36 / NO.OF BEDROOMS BUILDER O OWNER L��S PERMITDA - `- �9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) —".Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Furnished by Feet jS 1, 3y i/ , No.. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes w PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS, 01pprication for Migotar *pttem Con!5truction Permit Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No./ p ,pcPi� �fQ I Owner's Name,Address and Te-No. Assessor's Map/Parcel (J/��� Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel.No. 'Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(,e-,510 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 'el ���'1�7�.� Description of Soil Nature of Repairs or Alterations(Answer when applicable) € Date last inspected: Agreement: The undersigned agrees to ensure the construction and.maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enyi ,ottmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his Bo of,'' e Ith: / Signed Date �/�V/Ae Application Approved by _ %4 Date Application Disapproved for the following reasons Permit No. Date Issued ® u - - - _ _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER IFY,that}Ahe On,n-site Sewage Disposal System Constructed( )Repaired(!/)Upgraded( ) Abandoned )by ®/ , u/ 6 5d%'s,r, at A k has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, s dated Installer Designer The issuance of thi p shal(not be construed as a guarantee that the 'll function as d�s`igned� Date r Inspector -------- --- — ---------------- /U / ( Z � Fee- No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi$po$al *p5tem� on!9truction Permit Permission is hereby granted to_Construct( �Repair( ✓)Upg"( ) ndoq( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of Date: Approved 00 � g 1 TOWN OF BARNSTABLE LOCATION � SEWAGE# WLAGE C l� �"1l��ly - ASSESSOR'S MAP & LOT i' INSTALLER'S NAME&PHONE NO. ` � � o/fig SEPTIC TANK CAPACITY, 0©/I �/�� LEACHING FACILITY: (type)-2k %lei 1J (size) l e3L Z/d p NO.OF BEDROOMS +BUILDER O OWNERJ` PERMITDA Zg !� COMPLIANCE DATE-.--. i,Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `�� Feet Private Water Supply Well and Leaching Facility (If any wells exist'' on site or within 200 feet of leaching facility) Feet i Edge of Wetland and Leaching Facility(If any.wetlands exist within 300 feet of leaching facility) 'y. Feet Furnished by Rower. , d f�. m s b 3q M +yv i I r M" NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERINUT (WITHOUT DESIGNED PLANS) L �f1 J� tT�®r/W"6ereby certify that the application for disposal works construction permit signed by me dated ll6t�� , concerning the property located at l �f�' ��y 1'—'-f&.;' k4geets all of the following criteria: VThe failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified as I e percolation rate is less than ore " / CLASS and the pe o equal to � minutes per inch. 41 There are no wetlands within 100 feet of the proposed septic system P There are no private wells within 150 feet of the proposed septic system l+� There is no increase in flow and/or change in use proposed ere are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the mammtun adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor /method when applicable] I- If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: L A) Top of Ground Surface Elevation(using GIS information) ` B) G.W. Elevation +the MAX High G.W. Adjustment. DIFFERENCE BETWEEN A and B SIGNED : DATE: �`l blI7 P [Sketch proposed plan of system on back]. q:health folder.oat