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0020 EVELYN CIRCLE - Health
20 Evelyn Circle Centerville A= 187 062 003 llll � UPC 12534 ' No.215_OR YAiTlYYi.YY ��v `09 2015 00:28 Jim The Inspector Man 5085349919 page 1 a Commonwealth of Massachusetts Title 5 official Inspection Form 'r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments X Eve l n Circle y Property Address 1 Warren&Karen c' __... a ... ...__ __._ _..._. ...._. owner Uwner's Nerr+e information is -" required for every Centerville MA 02632 1-7=15 1 page_ CftytTown State Zip Code Data of Inspection T. 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; v __® _ ....... _.___.�._.__._ Important.outf When A. General Information onout farms //27/ ���tittinOF,0y on the computer, `�,ti� �4{01=�? �fy'zr�, use only the tab + �'� v L. k,Y. key to move your 1. Inspector: cursor-do not James D Sears JAMES ' use the return -... ... ..... ....�....__ _ q key. Name of inspector 10-1 Gaewide Enterprises LLC � _._.__ �-. -r_........._ r i Company Name _ �f R rtyt, 1 _ 153 Commercial Street _...... ----.. �...._. Company Address Mashpee _-_ _ _.. ....._.. .__ MA 02649 Cray/Tov✓n State dip Cade 506-47778877 S1623 Teephone tVumber Liense Number ................._..... B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15:000). The system: Passes [ Conditionally Passes ❑ fails ' ❑ Needs Further Evaluation.-by the Local Approving Authority 11-7 15 o _ _pector's 5i nakure _.a..._.. te 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, his report only describes conditions at the time of i ..**T inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the futur8 under the same or different conditions of use. ' ,5,,;s•3113 7Wo.5 Oq crel hspecwnrotnr Subsuriaoe savage Nspmw Cyslgns P07.,^n{t? Nov '09 2015 00:28 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments jq_�veylyn Circle property ma Warrem & Karen Owner .............. ........... s Name information is required for every Centerville ................... MA 02632 ......... 2 11-7-16 . . ................................... ................... page. City/Town State Zip Code Date of Inspedi" B. Certification (cont.) Inspection Summary: Check A,B,C,ij or E I always complete all of Section D A) System Passes-. 0 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are indicated below. Comments: _T-t S-e y Tank D Box and pit. -ste m is a 1000 Gal ...................- .......................... .............. .................. ...... ....................................... ............ ................................ ................. ........ .......... 8) System Conditionally Passes: D one or More system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, Will pass. Check the box for"yes', "no" or"not determined"(Y, N, ND; for the following statements. If"not determined,' please explain. The septic lank is metal and over 20 years old* or the septic tank (whether metal or riot) is structurally unsound, exhibits substantial infiltration or exfiltratlon 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 did is available. 0 Y ❑ N N6 (Explain below): ........... ............................. ... ........................ ..................... ........................... ................. .................. ............ ..................... .................................. .......... ............ ................... TiV 6 Oi?ido1 SvbSWrj- $Y619,n•Page 2,4 Nov '09 2015 0028 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Eveylyn Circle PI-OPerty Address Warrem & Karen Owner _N Ni -,--a Me information is required for every -Centerville ... ..... —MA 02632 11-7-15 page. -Centerville n . State Zip C*bda Date of Inspection B. Certification (cont.) E-1 Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 9) System Conditionally Passes (cont.)., ❑ Observation of sewage backup or break out or high static water level In n ihe:distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System wil! pass inspection if(with approval of Board of Health): El broken pipe(s)are replaced El Y n N El ND(Explain below)., El obstruction is removed El Y R N FJ ND(Explain below).- El distribution box is leveled or replaced 0 Y Ej N E] Na (Explain below), ............ .................... ...... ......... ............ .................... ....................... .............. ........ ........................................... ................................ ....... ......................................... I. ............................. . ............... .................... ................. El 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): n broken pipe(s) are replaced 0 Y Ll N El ND(Explain below).- El obstruction is removed 0 Y (:1 N M IND (Explain below); --------- -7- ..................... ................. ............ ......—------- ....... -- ------ 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, SyStOrn 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 n1arsh 15im; 3r3 Olic'M lnsxct 6f,Fatm Subsuduc-:i Stwil 3 01 17 Nov '09 2015 00:28 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 official Inspection Form bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........ 20 Eveylyn Circle ....................... .............................:....................... ..................................... Property Address Warrem &Karen_ Qwner --— - - ----------- information is required for every ,Centerville.-,.............. MA 02632 page. Gityffown sla t.a Zip Code .............____............... .......... Dwe of Inspection B. Certification (Cont,) 2- System Will fall Unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning In a manner that protects the public health, safety and environment, ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, El The system has a septic tank and SAS and the SAS is within a Zone I of.a public water supply, 0 The.system.has a septic tank and SAS and the SAS is within 60 feet of a private water supply well, El 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 6 ppm, provided that no other failure criteria are triggered, A copy of the analysis must be attached to this form, 3. Other. ........................................ ... ............ ................ ....................... ....................................... .......... .................... ............................... .................. .............. ................................ ................... ............ ...................................... ....................... ............. System Failure Criteria Applicable to All Systems: You Must indicate"Yes" or"No"to each of the following forg.11 Inspections; Yes No ❑ Backup of sewage into factlity 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 munqW0 is less than 6" below invert or availtible volume is less than %day flow T:tio 5 Ovicial Inspection Nnp. SubS0906 5"Age DiV, 0W 8VVe'11 0�9e4 of 17 .......... Nov 09 2015 00,28 Jim TiFe Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form 4: W Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 20 E.veylyn Circle Warrem & Karen Owners Name. owner — �__...... _ —. _ _.... ........_�... __, information is required for every Centerville _ .... ____...__ ...�...._._ MA:.._._.... 02632 11-7-15 page. CityrTown _ __ ....____. State Zip Code Date of inspection B. Certification (cent.) 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. ❑ z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ i Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis, [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal collform 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 forma ® The system is a cesspool serving a facility with a design flour of 2000gpd- 10,000gpd; ❑ ® The system fails, I have determined that one or more of the above failure criteria exist as described in 31a 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 roust serve a facility with a design flow of 10,000 gpd to 16,000 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 ❑ thesystem 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_ ra:nr.3t� Hia 5 o iva;fnSp9crion roril,S01si faa.,SeNao t}fapc>s�1 Sysivn pages a'17 Nov '09 2015 00;Z8 .iim The Inspector Man 5085349919 page 6 441, Cammonwealth of Massachusetts Title 5 official Inspection Form 3 Subsurface Sewage Disposal System Form Not for Voluntary Assessments A* 20 Eve i n Circle _._...._........._ Yam.,...._........__ Property Address Warrern& Karen --. Owner Owrer's Name information is required for every Centerville MA 02632 1 t 7 'S page. city(fown State ip_Code la 1.te o`tnspection 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) z ❑ 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 it 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: Z El Existing information. Fear example, a plan at the Board of Health_ ❑ Determined in the feld (if any of the failure criteria related to Part is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flaw Conditions: Number of bedrooms (design): --.NA - Number of bedrooms(actual): DESIGN flaw based on 310 CfMR 15.203(for example: 110 gpd x#of bedrooms): 33,0 Min,•3ii Tit-.5 Orf:ia!tnot ectwt,�efm:6ubs+Aiasm 6rrvapra rN 4rasml$jwii�.m•raoY! rvs 97 Nov 09 2015 00:28 Jim The Inspector Man 5085349919 page I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 EveyIvn Circle ............... ........................-—-—------ ...................----.......... ..................... Properly Address Warrem & Karen Owner6-m—ne rs Name ......... ............................... ........................----............................................. inforrnafion is required for every Centerville................................... ............. 02632 11-7-15 page. Cltyffown ................................. ... .... ... ............. State Zip Code Date cvf�lospectlon D. System Information Description.- jqq.system_(s_a 1000 Gal, Tank D Box and pLt,.......... . .....- ... .......... .................. ....................... ....................... ...................... .............. .................... Number of current residents: 4 Does residence have a garbage grinder? 0 Yes E No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) 0 Yes F] No Laundry system inspected? U Yes H No Seasonal use? Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): NA--................. Detail.- .................................. ....... ................ .......... .................... ........ ........ ............. ..................................... ....................... ............... Sump pump? ❑ Yes N No Last date of occupancy,- Present Date CommerciallIndustrial Flow Conditions: Type of Establishment: ................ ....... Design flow(based on 310 CMR 15,203): Gallons Pei 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 0 No Water meter readings, if available: fN 5 CYricim';triqrvejg.Q co" Subsurface Sysiom•Page 7 of 11 Nov' 09 2015 00:29 Jirn The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Eveylyn Circle Property Address Warrem & Karen Owner C+wner's Na.me information is required for every ._Centerville MA 02832 11-715. page. CityiTowrn State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: . . D.ate Other(describe below): .. . .... .._ M__..... ......._._. General Information Pumping Records: Source of information: NA Was system pumped as part or the inspection? ❑ Yes (Z No If yes, volume pumped _,,.. . A __-_ ..... gallons How was quantity pumped determined? __ _ Reason for pumping:. ....... ..._.......... —•- Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑ Shared system (yes or no)-(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A.system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): - Tilte 5 Official Irsped'an Porm:Subswfes Se aAge ilisposal system.pRge a of-, Nov 09 2015 00:29 Jim The Inspector Mari 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection For .11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Eveylyn Circle F W I 111_1_1_1 ............ ................... ...... rop �,,;�drei� Warrem & Karen OwnerOwner's Name ........................... .................................------------- ............... illormation is required for every -_Centerville MA 02632 ...............page. cilyrrown State Zip Code Date of Inspectior) ........... D. System Information (cont.) Approximate age of all components, date installed (if known) and source of info'rmation: Na New D Box 1 1-20M ........................... ......................_.............. ...................... Were sewage odors detected when arriving at the site) Yes ED No Building Sewer(locate on site plan): Depth below grade: 3' ................. reei Material of construction: L1 cast iron 40 PVC El other(explain),- ............... Distance from private water supply well or suction line- feet Comments (on condition of joints, venting, evidence of leakage,, etc.): __.Plipetg,is 4" PVC SCH 40 ............ . ................ ........ ............ ..................... ............ ................. ..................................................... ............ ........ ................ ................... ........ .................. Septic Tank (locate on site plan): Depth below grade: feet .............. Material of construction: concrete 17 Metal ❑fiberglass El polyethylene ❑other (explain) ........... .1........-........... ............. .............. ...... ................ .... .......... .. ................. .............. ................. ........... If tank is metal, list age: ................ ............. ........................ years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes ❑ No Dimensions: 1000 Gal. Precast 1+10 Sludge depth-, .................... ................. Titp 5 OrMW 111SPAr.'MA Form,Su"teace so,,ave Dsposa!syvem-Page 9 t:f T- Nov 09 20115 00:29 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts 2 Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments xa 20 EveY l_Y n Circle ...._.... . ........... --._............... ....._........... Properly Address Warrem &Karen Owner C7wner's Name information is required for every Centerville MA 02632 11�7 16 page, yfrown_.. .. State Zip Cade Date sl Ihspeetian D. System Information (cont) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" — - i„ Scum thickness __...-....... __._.._...........:..._......... 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 17 - _._......___...................__.._ Flow were dimensions determined? Asbuilt Tape 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,): Tank at working level. Tank at ' below grade w/covers at 4"% Inlet tee, outlet-baffle. No sign of e. leaks _.._..g..,-,___..__ .......____ ,_.. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: C7 concrete 0 metal C1 fiberglass El polyethylene other{explain}: Dimensions: Scum thickness 1 Distance from top of scum to top of outlet tee or baffle ._... _..... E Distance from bottom of scum to bottom of outlet tee or baffle — -.— — --_._._. .._.____ j 3 Date of last pumping: fate Eslr=..a ,,.x 7;1e 5 00daE tr,epWmi Form:wt mjtl,oa Srw i94 t*pz)gal SyWigr•Paps!r)ert 1 r i Nov 09 2015 00:29 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Eveylyn Circle I....................... ............. .. Property Address ........ Warrom & Karen Owner information is required for every CentervilleMA.............................. 02632 page. Cltprrown _ State _�:pCode Date of lnspecT 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.- CD concrete 17-1 metal ❑ fiberglass polyethylene ❑ other(explain): ................ ...................... ...... .......... ..................... Dimensions.- ... .................... Capacity ........ ...................... ...... .................... gallons Design Flow: ------ ................... gallons per day Alarm present: ❑ Yes ❑ No Alarm leveL ................... Alarm in working order. El Yes El No Date Of last pumping: . ........ ............ ...................... Date Comments (condition of alarm and float Switches, etc.): ................ ............ .. ........................... ....... ........................... ..................... ................. ........................................ ........... ............. ........ .............. ................... Attach copy of current pumping contract(required). Is copy attached? D Yes F] No 0"'r:W hlr'eclbkj'�Fwm:Subsufiki Sewaga Dispasa:syslemn•rage I 1 of 17 ' mov uy 2015 00:29 Jim The Inspector Man 5085349919 page 12 Commonwealth OfMassachuseft Title — .- ~ ~ . ~^.~~^ Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Owner - _- mmnnaio*Is required for every MA page. u»".own �a Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site p|an): ' � Depth cf liquid level above outlet invert u Comments(note if box is level and distribution to outlets equal, any evidence of so lids carryover, any evidence of leakage into or out of box, etc,)� ' O Box_is1 d w/one | -2015_w/cxmra �6' __--................._...... .... .... ....-__- -..... ~_-__________'-___-'_' ....__ ................... _ .......... -__... ......... ______________-_ - .............._--- _......._______ ------ -__......._--... .............. Chamber(locate on site plan): ' Pumps in working order.- [J Yes [] No* Alarms in working order: ye- [l W | Comments (note condition of pump chamber, condition of pumps and appurtenonoeo.ehz.>� � ` ' ` ° If pumps or alarms are not in working order, system is a conditional pass. � Soil Absorption (SAS)(locate on site plan, excavation not required): |f SAS not located, explain why: ' / o��vai Sym="'page i;1.m,, � - Nov' 09 2015 00:29 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts ,_ Title 5 Official Inspection Form 'nr Subsurface Sewage Disposal System Form -Not for 1Jo'untary Assessments 20 Eve Yy I n Circle .r.._ _ roperty� ddress Warrem $ Karen Owner __ _._—---- Owner's f+larle information is required for every Centerville ..,._.___ .... MA 02632 11 7 15' page. Cityfrown .- ........ __ . State Zip Code Date of Inspection D. System Information (cont.) Type: _ 1 leaching pits number: ____.__........... ..____......__.. ❑ leaching chambers number; ❑ leaching galleries number; leaching trenches number, length, __ ........__.._.. leaching fields number, dimensions: _......._......__.._._.v...._. .._. ❑ overflow cesspool number: - —.__._................._� ❑ innovative/alternative system Y Type/name of technology: _ .._..,...... .......... _.........--......_..._:_............._. _................. Comments(note condition of soil, signs of hydraulic failure, level of ponding, darrip soil; condition of vegetation, etc.): Leaching is a 1000 Gal. Precast pit. Pit at 38" below grade w{cover at 7". T water in pit no sign, of over loadinq or solid car over. 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 15%:'i&•3113 OMcia �r,sPItClon rwrn&2ncr'aco;saw1ais'3is,-asa4 Sye;ca 3 nt t 7 Nov 09 20115 00:30 Jim The Inspector Mari 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form _9 .......... .......... Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Eveylvn Circle ........... Property Address Warrem & Karen Owner Name ..................... information is required for ,,,y Centerville ........ MA 02632..... ..........--....... .... ......... page. CityfFo-%vn State Zip Code Date of In'%pectiori ............................ D. systerW—Info—rmat'-i—on—(cont'.-)---'- Comments(note condition of sail, signs of hydraulic failure, level of pending, 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 pending, condition of vegetation, .................................................... ............ ...................................... ........................- .................................................. ................................................ ........ ................................. ......... ......................................... ............................ ....... .......... 5 Oftio;ktseeOxon Form 3ifb3uffmcq Svwag2 I)Isposel SysjArn•page 14 of 17 Nu� 09 2015 00-30 Jiro. The Inspector Man 5085349919 page 15 Commonwealth Of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ............ 20 Evevivri Circle Property Address .......... Warrem & Karen Owner Owners Name .....................- information is required for every Centerville MA 02632 11-7-15 page. City/Town ode _6ite of 1nspecVon _ 1p C State D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two Permanent reference landmarks or benchr-narks. 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 separale"y E�c K L]R :AP-: -33 00 -ale aJt3 Tole$Offidal S1,*Xd;m votm, ..................................... N,!v 09 2015 00:30 Jim The Inspector Mari 5085349919 page 1,6 Commonwealth of Massachusetts Title 5 Official Inspection Form .A il Subsurface Sewage Disposal System Form Not for Voluntary Assessments 20 Eveylyn Pircla -property Address VVarrem & Karen OwnprwnergName ................. . information required for every Centerville__ .......... MA 0263211____. ...................... ................... page, C71trfa State .. Zip Code Date of Inspedion ............... ................... D. System Information (cont.) Site Exam: ❑ Check slope ❑ Surface water ❑ Check cellar Shallow wells JV4) 12' Estimated depth to high ground Water: ............ ........... feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If Checked, date of design plan reviewed: Bate Observed site (abutting properly/observation hole within 150 feet of SAS) 0 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: H. 12. no GW. Buft Of Pit at 9� below grade. Bottom of pit a t Tabove T.H,. ............... ................ .................. .............. .............. ................ .................. ........................ .................. .................................. ........................................................... .......... ............. ....................... ....................................... .............. ............................. .................... ... .......................... ................... ............—---------....................... ........... ...................... Before filing this Inspection Report,Please see Report Completeness Check'llst on next page. T!Ue 6 Officj3j hspUC110r.Form.subsuriace se%%ga ujsposai sys .Page 1G 0,17 ............ ............. i Ndv 09 2015 0030 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20-Eveylyn Circle Property Address Warrem & Karen .Owner Owners Name information is required for every Centerville MA 02632 11-7-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C,D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)dompleted ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate fife tsine•3I15 fills 5 ORcal hwadon Form;Subsurtsca Sewage Dispasd 9yigem.Page 17 of 17 ' No. � Feel/00 � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for Misposal *- pstrm Construrtion 3pPrmit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. AQ C-Vi-CW E 1P, divicu5 Owner's Name,address,and Tel.No. Assessor's Map/Parcel 1Q CVet..4 N <q,M f � Installer's Name,Address,and Tel.No. 150 —477 917 Designer's Name,Address,and Tel.No. CAPi6-W bC "<— W 1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) AM-- gpd Design flow provided Ald gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) REPLY Boo Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate'of Compliance has been issued by this Board of Health. ed Date Application Approved by Date I Application Disapproved Date for the following reasons Permit No. L�^ �'p�'j Date Issued r No. ` Fee-� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes i,PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS ftpYication for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair( j Upgrade( ) Abandon( ) E]'Complete System )(Individual Components Location Address or Lot No. A0 CV ECW e 1P. Gt t va - Owner's Name,Address,and Tel.No. J WA'ku s K<kVtem NaL^ZES Assessor's Map/Parcel :-O (—:71/Ec s/IC/ <, deW �YLt!( Ljc; Installer's Name,Address,and Tel.No. Sp -cj7"7 g%1 1 Designer's Name,Address,and Tel.No. CAPEc..+r)E ttr�JTaL9V5fiS "'I-- � N 1A Type of Building: Dwelling No.of Bedrooms �,� Lot Size jsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A M— gpd Design flow provided A)/� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. - - Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) REA D w6 1 Date last inspected: i Agreement: ! The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in M accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ed Date 3" Application Approved by Date e Application Disapproved 000' Date for the following reasons Permit No. G�-- Qcj Date Issued 17j/Zpr THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed Repaired Upgraded > g P Y ( ) P ( ( )N Abandoned( )by C;AQi;�hj G E)�Y AL5EE� C LC— at ,;Q �.���%-IA� C to 0 r-r%XVj L( � has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. y-- 301 dated Z�o/5 " T� Installer �ti0�t)(n9 &a'i'8Q®�(,� �(�� Designer 1A4 #bedrooms /(J Approved desi flo /U{�} gpd The issuance of this permit shall not be construed as a guarantee that the system will func ion as designed. Date Inspector -----N ------------------------------------------------------------------- - --------- ------------------------------------- o. i Q �� 3 6� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction permit Permission is hereby granted to Construct( ) Repair(x Upgrade( ) Abandon( ) System located at ;L0 C;.VC—( \!6J C 1 RC(rC Q 1J[0LV1 UL LS and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Dated Approved by SEWAGE INSPECTIONS L ATION IQ is n C St(' • DATE VILLAGE C2 a� QQ;A D_ ASSESSOR'S MAP & LOT 87 0" � C 600 . cl SEPTIC TANK CAPACPI'Y ,On© LEACHING FACILITY: (type) LP (size) NO. OF BEDROOMS Y nr -QR OWNER !1 C�✓LSZri �' �,' OWNER MAILINg ADDRESS J w�` \\ \ � w \\ ` �� ♦\ \0 \ \ \ I �j � "�(\ !' ,g � �b � � f �.� �, � � � � \ J �` �� G ' e TOWN OF BARNSTABLE LOC�kTION 3 SEWAGE # VILLAGE /A ��G /�.�1 ASSESSOR'S MAP & LOT 197-00,,d&3 n� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) Za n/V �NO. OF BEDROOMS PRIVATE WELL O PUBLIC ATER BUILDER OR OWNERt f DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: — LyzL VARIANCE GRANTED: Yes No y � 1 w��1 4ea L`t� DATE 2115106 PROPERTY ADDRESS 20 Evelyn Circle Centerville MA 02632 On the above date, the septic'system at the address above was Inspected. This system consists of the following: 1. 1-1000 ga i2on zept.ic tank., �o2U 2.� 1- Dizta igut.ion Box., 3., 1- 1000 gaiion eeach.ing 12.it., Based on inspection, I certify the following conditions: 4., 7h.iz .ins a 7.iUe Five ze/2t.ic zy stem., (78code) 5., The zept.ic hyztem .ins .in paope2 woak.ingoade at the /22eZent t.ime.- SIGNAT Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 1 Phone: 508-775-3338 or 508-775-6412 CEPH P. MACOMBER & SON, INC..Tanks-Cesspools-Leachfields .-- Pumped & .installed co Town Sewer Connections . Box 66 Centerville, MA 026.32-0066 775-3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS r EXECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS > DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM NOT FOIE VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: . 20 Evelyn Circle Centerville MA 02632 Owner's Name: Karen Holmes Owner's Address: Same Date of Inspection: Name of Inspector:(please print) RRbAKt A Paolini Company Name: __? % (7acom&ea & S.o.n Inc. Mailing Address: C.en ezv p TEE, a7.s.-026 32 Telephone Number: 5 0 8-.7 7 5-3338 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 z.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 M000). The system: XX.tpasses Conditionally Passes I� urther Evaluation by the Local Approving Authority F ils Inspector's Signa re: - 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. Notes and Comments ****This'report only describes conditions at the time of inspection and under the conditions of use at that �. system will perform in the future under the same or differ"t time.This inspection does not address how the conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Evelyn Circle Centerville MA 02632 Owner: Karen Hot meG Date of Inspection: Inspection Summary: Check AJ3,C,D or.E/ LW.AYS complete atl of Section:D A. System Passes: YES NO I have not found any information which indicatestiat any of the failure criteria described in 31-0 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Seftic zyztem .ia .in ao e2 woak.in oac�ea at th/� /� g e R2e,3e.nt time. B. System Conditionally Passes: n o 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. n o The septic tank is metal and.over.20 years old*,or the septic tank(whether metal or not)isstructurally 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: n c' 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: n o 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:. . r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI.FICATION(continued) Property Address: 20 Evelyn Circle Centerville MA 02632 Owner:. Karen Holmes Date of Inspection: C. Further Evaluation is Required by the Board of Health: NO. Conditions.exist which.require further evaluation by the Board of Health lin order to Aetermine 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: n o Cesspool or privy is within 50 feet of a surface water n o 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 mRnner that protects the public health,safety and environment: n o 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. n o The system has a septic tank and SAS and the SAS is within a Zone 1 of a.public water supply. rz o The system has a septic tank and.SA&and the SAS is within 50 feet of a private water supply well. n'o The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well Method used to determine distance v.i 6aa 2 **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: 3. r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 20 Evelyn Circle Centerville MA 02632 Owner: Karen Holmes 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 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 thank"below invert or available,volume is less than'/s.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 Zont 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 morepf the above failure.criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner uld 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is.located in a nitrogen sensitive area(1Tnterim 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 t Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALlSYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Evelyn Circle CenterVillP MA 02632 Owner: Karen Hc)1 mPg Date of Inspection: 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? NIA 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)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 Evelyn Circle �'pnteruille NA_ 02632 Owner: Karon Nnl meg Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . 3 Number of bedrooms(actual): Z DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 220 Number of current residents: 4 Does residence have a garbage grinder(yes or no): rz o Is laundry on a separate sewage system(yes or no):rz o [if yes separate inspection required] Laundry system inspected(yes or no): n o Seasonal use:(yes orno): no 2004=121., 000 gaeeonz G1)[7_331., 50 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5_151, 0 n Q.I7a i e o n z g 0 D=413. 6 9 Sump pump(yes or no): n o S z n k ?e 2 t e m h Last date of occupancy: ?,,z e.6 e n t y pli e z e n t.- COMMERCIAL/I1bUSTRIAL Type of establ�s ent: N 1,4 Design flow(Based on 310 CMR 15.203): apd Basis of design'flow(seats/persons/sgR,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: NA4 Was system pumped as part of the inspection(yes or no): 0i5 If yes,volume pumped:000 gallons--.How was quantity pumped determined? Me_a4V�ed 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 hown)and source of information: unknown .,,' • Were sewage odors detected when arriving at the site(yes or-no): no 6 r.. 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: 20 Eve 1 yn C i r c l e �_antQr-yi 1 1 e MA 02632 Owner: Karen _Hnlmcc. Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 20 f0 f o o t Comments(on condition of joints,venting,evidence of leakage,etc.): 10 intb a1212 ahf nn 6 1 gU ba 06-1 669e. SEPTIC TANK:y e Xlocate on site plan) 10 0 0 ga e i o n tank., Depth below grade: 18 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) I . Dimensions: 8' 6'X5' 8'X-4' 10" Sludge depth:_t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: t a a c e Scum thickness: t 2 a c e t 2 a c e Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: t 2 a c e How were dimensions determined: m e a z u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): Pump tank eU 0rin.t Tn 7anlc GREASE TRAP:n o (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 a related to outlet invert,evidence of leakage,etc.): j2eaze t2a/2 .is not R2ehent 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: 20 F.val Un ri rr-le C'antArvi 1 12 D41 02632 owner, xa ran Hr%l M®s Date of Inspection: TIGHT or HOLDING TANK:n o (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.): 7ight oa ho �dinq tank,6 ate not Pzezea DISTRIBUTION BOX:�e S(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.): Box i.3 _Revel., NO zzgnb O. zoJid CnirnU»non nn forikriga ;a o4 out o� fox: Box ha.6 2 eatelzaez.! PUMP CHAMBER: n o (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.): PtLmI2 chamRea iz not pzezent 8 Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS. — SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION(continued). Property Address: 20 Evelyn Circle Centerville MA 02632 Owner: Karen Holmes Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located .6 e 12age 10. Type X leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Loamy to medium .sand., No zign,5 o� �a.iiurte zo.iez aae d2y., vege a ion .iz noama.e. CESSPOOLS: n o (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.): Ce2,3,s1zoo1.6 a a e not aezeat 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.): l a.ivy .c's not /Zze-ent 9 _ _ J Page 10 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Evelyn circle C'pri Prvi11P MA n2632 Owner: Karen Hnl mac 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 benchmarks:Locate all wells within 100 feet.Locate where public water supply enters the building. 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: .20 Evelyn Circle Centerville MA 02632 Owner: Ka en Hol mac _ Date of Inspection: 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: •N 0 Obtained from system design plans on record-If checked,date of design plan reviewed: u e z Observed site(abutting property/observation hole within 150,feet of SAS) Checked with local Board of Health-explaimaz R �i D t caitd no Checked:with local excavators,installers-(attach documentation) Accessed USGS database=explainA t;E/R:town.,l;_a anis t a lg t e.-m a. u!s —, You must describe how you established the high ground water elevation: llaed. : Cape Cod Comm.is.eon 1datea 7ag2e Codtou4h And Puglia Uatea Supply Oeii head Raoteetio-n aaeaz map., Seat 1995 Nate2 aezouncez o;0_,ice cane cod comma ion Top of Oroun6— Leaching Pit D: eet GroundwateA Feet Below Bottom;of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 .. ''•' 3{ •nnnnr rwrn'+•►rwrwRennw7�'7rrra7nVeN1/rwP►4Hf1F71�rF11.l.wflTw�t +IA'Im!�itZr•.r�••1; TOWN OF. BARNS2:Aj5TjE BOARD OF HEALTH 1 SUBSURFACE SEWA09 DISPOSAL SYSTEM INSPECTION F01 M - PART D•r CERTIFICATION , --win T. 1 �w �+••ar r -TYPE OR PRINT CLEARLY- PROPERTY INSPFCTFI? STREET ADDRESS 20 .Evelyn Circle Centerville ' ASSESSORS MAP, BLACK AND 'PARCEL 0 OWNER's NAME Karen Holmes PART` D 0RRTIFI0ATX0N NAME 'OF INSPECTOR Ro 8 eat Pa.o.,bn i41 ' COMPANY NAME Aze-l>h. :P., Placom&ea''J. ' Son Inc " COMPANY ADD.Rg3S Box 66 : 'Cen4g/tV.iUa Oabb' 02632 ' Stre4r. Torn or City State LIP COMPANY TELEPHONE ( 508. )'�7.5 3338 FAX (' 508',1190 f 578 QURT-hFICATION. STATEMENT I I.certify that I helve personally .inspected ..the sewage 'digposal. system at this address and that- ;th_�d' information reported .is true#. soeUra•te-i and omplete as of the time .a;f inspection..• The inspeotiorn was per-farmed and any recommendations regard.ing upgraded -maintenance ,, abd repair .are• eon$is•tent with my trainiklg and exp.e'rience in thq proper futToti-on- and maintenance of on- site sewage disposal systems. • �� • 1 Bpi{i1, Check one: Systea PAS'82D The inspection which •I have .conducted has ,,n-ct found any. information . which indicate* that the system' falls to ' adequately. protect .publiv health or the enviropment as defined in- .310 CMR. I' 30.3-, Any failure criteria t,ot evaluated are as stated in the FAI•LURM' CRI ERIA see.tion of this form. System FAILED* The inspection which I have co'n ted 'has'.'•found that the system fails to protect the public health gtnd the envlronmen•t ' in aogord-ante with Title 61 310 CMR 15 . 303, and as - specifically noted on .Pk'.T' C -� . FAILURE CRITERIA of s inspec' ion form. Inspector Signatu Date Vne' copy of this cei% f i..cat.fob must -be provided 'to : the .9MR•I th1B.EUYER where applizable) and- trh� DQARD OF HEA ill. ; * If the inapection FAIL'Eb.� thb .owne'r' .orr"operator -vh4Lll . upg•a!►de'.the system. within one year the date of the in8pectionj unless. allow sd ar• required f.harw{se as Provided in qJ0 CMR 15 r 306.r. • •• .