HomeMy WebLinkAbout0021 FAIR OAKS ROAD - Health (2) 21 Fair Oafs
CI
Centerville
A� A= 1681—092 004
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1521/3 ORA 105'O P2
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
=L � 21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville V/ Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. Inspector Information
When filling out p �/* 11-11-Y(Ag
forms on the
computer,use Douglas A Brown
only the tab key Name of Inspector
to move your D.A.Brown Inc
cursor-do not Company Name
use the return
key. P.o Box 145
Company Address
� Centerville Ma 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
3-27-2020
f-nspep,Ws Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. -
Comments:
At time of inspection this system met all minimum passing requirements. this system is from 1987.
This report can not predict the future performance under the same or increased usage.This report is
not to be used for bedroom count determination we are going by the original permit for 3 bedrooms.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health..
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
1
Commonwealth of Massachusetts
�u IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
li� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/20111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
l-F Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�. IF Title 5 Official Inspection Form
I
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L�
21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® El information
the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
AN
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^ � 21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): unknown
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
According to plan a 1000 gallon septic tank d-box and leach pit are shown. There were no as-built
cards availble at the Board of Health. We were able to locate a septic tank and leach pit(not the d-
box).
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): see below
9 ( Y 9
Detail:
372.6 gpd average for 2018 and 2019
Sump pump? ❑ Yes ❑ No
Last date of occupancy: currentlyoccupied
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
r
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityrrown_ State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: pumped 1000 gallons at time of inspection for
maintenance
Was system pumped as part of the inspection? El Yes El No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? tank truck guage
Reason for pumping: maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
u lP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
L
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1987 per permit( no D-box found due to no as-built)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
I.? Title 5 Official Inspection Form
° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon per plan
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was pumped at time of inspection for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
l�F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Not found no as-built card at B.O.H
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
AN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
~ III
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1 6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form Not for Voluntary Assessments
L � 21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit had 14 inches of usable space at time of inspection actual liquid level was 21 inches from the top
of pit. top of pit was 32 inches from grade with 1 riser.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
,�-p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
=v / 21 Fair Oaks Rd
Property Address
owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
4-
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
N - - - - t
\)w-32,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�A ,.? Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form Not for Voluntary Assessments
^ � 21 Fair Oaks Rd
Property Address
Owner Keston
information is
Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 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: 3-27-2020
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:
design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I __
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Io
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
21 Fair Oaks Rd
Property Address
Owner Keston
information is Owner's Name
required for Centerville Ma 02632 3-27-2020
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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Design Flow........IA-C:).........................gallons per person per day. Total daily flow..........��,.�..o
. ................gallons.
Septic Tank—Liquid capacity/120 &? ?gallons Length ��.. Width_ .,'10". Diameter.......:-.... Depth..�_r�._+".
W Disposal Trench—No. ............... Width.................... Total Length Total leaching area....................sq. ft.
3 Seepage Pit No..Q_.N..9tt..... Diameter...... Depth below inlet..&............ Total leaching areaZ66.s.q..sq. ft.
Z Other Distribution box Dosing tank )
Percolation Test Results Performed b .T).A•,..14!1!!'lA ..................... Datel?�;/ 3 f$
.a
Test Pit No. 1.G. ...minutes per inch Depth of Test Pit....l.22-�...... Depth to ground water..4P/J-fir.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil.......Z. FT,,.. m __5lS"P solC_ .. �. ...•.%.. ..�.r�.f .G±1=....Grl. -.......
....
r�. LIY1.....�l� >�>b .
VW ......................... ..•-----........•--------------•--..............------..---•-........---•--------------------------=---.._.............,.........._..._......--••---••-•------•........-•-•-•
Nature of Repairs or Alterations—Answer when applicable..................................................................................0............
.........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the•aforedescribed Individual Sewage Disposal System in accordance with
the provisions of MIL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
Woperation1 ert' sate of Compliance has been issued by a health.Signed..... ..... .................... . ...�.,5�._....
pproved B .... !®:�-�: ................ -• ` l ......
Date
Application Disapproved for the following reasons:................................................. ............................................................
.............................................................................................................:...........................................................................................
Due
Permit No..... ...... .......__ Issued..............................
..-••---...» ....»
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
—No 2. 4 Z—
....................................OF..........1 ►.� ......---...............�.......................... FSs. ........
�is�r,a�� urk� �u�inn �rrmi#
Permission is hereby granted........'.... 4.1.................... .._
to Construct Repair ( ) ad indr" idiral Sewage Disposal-System
atNo................................................... ?!!2
Street C��_
as shown on the applicatio for Disposal Works Construction Perio.':5 _........:1. D d:........................................
....... n... ...............•..-•-•-
do
Z ............. Board of ealt
DATE.----- .-•-.--• :.
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OF HEALTH
1 —Tr)UJ...................._ ..................
Appftrtttiun for Disposal Works Tonutrudiun Itrrmit
1 ,0 Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: _............... Fp--.._... - - ------ - L --- ....
Location•Address or Lot No.
�
..............._ __�- _ - �l ..........................................._.........................._...._........
94 live,, '�• �� Address j
a - ---....--•......... ......•--•--•.............................••--.............------......•-••--........._..........
M Installer Address
Type of Building 3 Size Lot. .�:.4 27—.`.�:...Sq. feet
U Dwelling No. of Bedrooms.............................. .....Ex Expansion Attic _
� ng— -..-.-.-- pa ( ) Garbage Grinder ( )
aOther—Type of Building .........:.................. No.. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures ........................•---._.........._......--•...... ....--•........................-••-•-.._....••••-•---•--••••--............--••--•...•.....
Design Flow........a. �"a._____...-•--•............gallons per person per day. Total daily fl -----:
ow...........3..�--.. ................gallons.
�
Septic Tank—Liquid capacityLI2(2Ogallons Length�P�-".. Width;!!!f.,O�' Diameter:-. .... Depth.-�_.!` �
:...
Disposal Trench No. .._.. Width.................... Total Length Total leaching area....................sq. ft.
3 Seepage Pit ..... Diameter......!:....... Depth below inlet.. .1.......... Total leaching area_;;!66:.9.-sq. ft.
Z Other Distribution box O Dosing tank ( )
Percolation Test Results Performed by....T:. ¢.:. *� . . Datedj....... ..�
f= Test Pit No. 2........... ...minutes per Inch Depth of Test •- .. .
Pit....?. : ...... De' to ground water..!`:(':-:
,.,.1 Test Pit No. 1.......�.._.minutes per inch Depth of Test .Pit.................... Depth to ground water........................
O Description of soil......` '1"_---o;� �l�T�_•o i L.. .. ................
V ----------
--------- ---lt� c-- I1.lH---------- �. ..------'�t-12 ------
-.------------
------•-•- -----------
UW ...........................•------....-----•-•-------•--•-------------•-.........-•••-•......--•.............-----------................-----•............_......................---.................•••
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..-•--•-•---•.......................•-•••••-•-•---•..--.................................••-------•..._..........------...-••-•--•-------.......•--....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation uptil a ertilt3cate of Compliance has been issued by/the
board of health.
Signed.. . ...................... ...•I 1 /
/-D ., .
ate�� tion PProvdB .................... ........ ......
Application Disapproved for the following reasons:.............:..........•------•-•-....-----...---•--.............------•--------..........••--..........---
ue
Permit No......�arn---ro .............. Issued.. ......... ...............D ......
Date
Ft!!*33t 18V4.»a�:_,TpP�4?.ag�.�,r�3,-3+oy�s nrc.waw_ _-.sa,?.r.,....s:;.F�caa.T-4 MCv=#lEz�.-P+5212`
THE COMMONWEALTH OF MASSACHUSETTS
._�_-.= HARD OF HEALTH
(.�
......................./�1.+,r'...OF.............l. q_jfEM.......,......................................
Trrtifirtttr of Tumplinnrr
b .THIS IS TQ CERTIFY, Tha •the It ct i�'vjdual Sewage Disposal-System constructed (-•Repaired
p(....
)
y - Installer
........................................_ .......--•••-
has been installed in accordance with the provisions of TITLE- 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...`.!.�._��.. ....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................................... ..................... Inspector... . .... ........................................I..................
Barnstable Assessing Search Results Pagel of 3
S Z9Y�Td'it&. RX
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1 3t New Interactive Maps >>
Owner: 2006 Assessed
Values:
KESTEN, ROBERT JR&DAHLIA
21 FAIR OAKS ROAD Appraised Value Assessed Value
Map/Parcel/Parcel Extension Building Value: $372,100 $372,100
168 /092/004 Extra Features: $4,100 $4,100
Outbuildings: $20,400 $20,400
Mailing Address Land Value: $236,200 $236,200
KESTEN, ROBERT JR&DAHLIA
Totals $632,800 $632,800
21 FAIR OAKS RD
CENTERVILLE, MA.02632 '
2006 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Community Preservation Act Tax $ 100.84 Fire District Rates Town
Barnstable-Residential $1.90 $6.31
Barnstable-Commercial $2.51 Commei
C.O.M.M. FD Tax(Residential) $670.77 C.O.M.M.-All Classes $1.06 $6.54.
Cotuit FD-All Classes $1.33 Persona
Town Tax(Residential) $3,361.34 Hyannis-Residential $1.61 $6.49
Hyannis-Commercial $2.50 Other R:
W Barnstable-Residential $1.60 Commur
W Barnstable-Commercial $2.46
Total: $4,132.95
Construction Details
Building Property Sketch Legend
Building value $372,100 Interior Floors Carpet
Style Cape Cod Interior Walls Plastered
Model Residential Heat Fuel Gas
Grade Average Plus Heat Type Hot Air
Stories 1 Story F A AC Type Central
Exterior Walls Wood Shingle Bedrooms 4 Bedrooms
Roof Structure Gable/Hip Bathrooms 4 Full + 1 H
http://gisweb/assessing/assess06/displayparcelO6map.asp?mapparback=parcel&mappar=16... 9/25/2006
Barnstable Assessing Search Results Page 2 of 3
Roof Cover Asph/F GIs/Cmp living area 3130
Replacement Cost $391654 Year Built 1988
Depreciation 5 Total Rooms 8 Rooms
Land ka��
CODE 1010 �W
Lot Size(Acres) 1.09 '4 � �
7 fist
7" ��
Appraised Value $236,200
k .
44,
:f
Assessed Value $236,200
-View Interactive Maps >
AfA
Sales History:
Owner: Sale Date Book/Page: Sale Price:
KESTEN, ROBERT JR&DAHLIA Feb 15 1993 12:OOAM 8459/113 $ 1
KESTEN, DAHLIA Apr 15 1991 12:OOAM 7506/287 $212,000
LANE HOMES INC Jan 15 1987 12:OOAM 5527/256 $ 1 ^"
A J LANE&CO INC; Dec 15 1985 12:OOAM 4856/325 $0
Extra Building Features
Code Description Units/SQ ft Appraised.Value Assessed Value
FPL1 Fireplace 1 $2,900 $2,900
DOR Dormer 4 $600 $600
DOR Dormer 4 $600 $600
SPL2 Pool Vinyl 800 $ 17,500 $ 17,500
SHED Shed 375 $2,900 $2,900
Property Sketch
Legend
BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area UST Utility Area(Unfinished)
(Finished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story
(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story
(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
http://gisweb/assessing/assess06/displayparcelO6map.asp?mapparback=parcel&mappar=16... 9/25/2006
r tr
F$s
e THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF, HEALTH
6f.l . -L
w ,} #.. iliftri iun.. for Disposal 106rka Tuns# ion Fermi#
q a _ 11 Applicatio hereby de r a Permit to Construct ( or Repair ( ) an Individual Sewage .Disposal
System at c- Glah. (JeC
Location Address q o
... .»..»�^w L..�ow •r Lot Na .. ....
Sew-• .... 1�...- .... »»Address ,. ..
�. �Installe ..r .. .».... ... ........... .. ... ..
Type of Building Aaaress ,.. ..
Size Lot.47iZ` '. .
_Sq feet
Dwelling—No. of Bedrooms... 3 Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building No .of persons............................... Showers — Cafeteria ( )
Other. fixtures ............ .... - ( �..... ..... `
...
Design -Flow..: h-c) gallons r person r O
._....--- gal per pe per day. Total daily flow .. ons.
t�
Septic Tank Liquid capacity/0PPgallons Length&..(?1.'Width.&1L�o�� Diameter..."..,. D c4r
W Disposal Trench--No .................... Width_
Total Length....:: �..,..,..Total leaching area....................sq. ft.
3 Seepage Pit'No..Q-. -19! �.
--.... Diameter...,.. �.._...:, Depth.below iiilet..,�?............Total leaching areaZ6�ai. . ft.
,. � �sq
Z Other=Distribution.box Dosing tank
a ?P rcolatiori Test Results Performed by...I c,�►� 1 1.5!!!1...,>...........
Test.Pit No. 1. .. ----minutes per inch Depth of Test.Pit...I 4 .......Depth•:to ground water..b4l2./J.�r...
Lt. Test Pit No. 2.... ........minutes per inch Depth of Test Pit.•....... .........Depth to ground`water.................
O Description of Soil. ... . FT,.................5 lS'F3 Sp I G.. - "Tb .�.it.f. GL E,acal:.......:...
v -. ....•. • . .M,..�P-�. ....�/ .......................... . . ...... .
w ............ ......... . ............
`V Nature of Repairs or Alterations—Answer when applicable.........
...........................................................
. .
Agreement: ... ................ _. ............ ... ...................................... ._.•. --••....................... .................
The undersigned agrees to ins all;the'aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:I.TL E 5 of the State Sanitary Code' The undersigned further agrees not to place the system in
>� o Pion u t ert', sate of Compliance has been.issued by health.
Signed: .................... g ..:....
p icatio PP roved B ..... . . ! :.
w Application Disapproved for the following"reasons: .. ................................ .... ate
y - ..... .................... ..,.... .. .....:
i } Permit NO.. .... �. � .. ..».. Hate
Issued.» .....
-
--'oMeiQ,R••-.o.„yt- •A,Y:•*�� -� �'-1�=..,,�i�..T,W,...,R,,.�'.�6�9.isc..,i:,<,.,,.w. .
_Yet
YtiE COMMt�P11NEALTfk 'OFMASSACHUSETT"�' x " ��F
RD F�:HEALTH
r.O. '
/.hr.! OF.............sl
.0. �.,A'nt .. Y x•.}t "� okp fix.. z .*,+
Ttif
THIS lS`T C. TI,`F,Y' ha, the 'I :vjdual',Sei&!.-qe'. ¢Disposal System cons�ructed ( or Repaired ( )
by ........k- - ;m �lnstafter;. .: .a1 �' $�
s .... .. ...............................
hAs been installed in accordanceY with the provisions of TIT' 5 of The State Sanitary Cde as"descr'ibed in%the
application for Disposal Works Construction Permit No...` r'.` dated
THE ISSUANCE OF'THIS CERTIFICATE SHALL NOT''BE CONSTRUE®`AS A'GUARANTEE THAT THE
SYSTEM WILL FUNCTION S/[1TISFAC70RY r,
DATE.....' ;Inspector E t
t .4"
pww-:xww rae,.wr na Rr ww,Awe4�rt rras r.r" tyre nauei-Ars.q, 4w7�►=ary u5tl wow tR r� r rr;r so.a ara nrrtrtirt cair rn��`rrs rw e� srew�:t#,sw Ka sr-s'�x .
S< r TH`!: COMMONWEALTH,OF''MASSAC?HUSETTS� +
'cd
4
a � r ' ' 6OARO O' M.EA} 'T '17� ..,.r;��
.41
OF .L,r
,s
Permission is hereby,granted r f/ " T k
to Coastru r'R T `a y t .oaf y ar r^ a d
( j-"+6 epai ( ) a Indtvadual Sewage Dispo System
..P - . .. ... ... .... .... ....
Street
as shown on the ipplicatio for Disposal Works Construction Per_ ' ot� �� � i_ D d"...
q
_
T...................
DATE. .. . .0 ara or ea�c
c+ - r.." _ '
4
Lt
` I
SECTION - SEWAGE
I -SEPTIC TANK - G{-I _"D"BOX I -LEACH
TOP F FON•
"L (MSL)r "2"OF Its TO lb"
WASHEO STONE
\ f
OUT• &\
IN•
DOO OUT• iN
3�.44 .OQ� SEPTIC
TANK G 35.83 351 c�o1j
ELEV. ELEV. ELEV. / \ �
Vru�er 3517513!5.5b .ELEV.
q # Lra�j- /
(� ELEV. ELEV.
TA��-►
" j
IO. WASHED STONE 'VO
,
.TEST HOLE LOG �_
Aly \
. I IV O
TEST BY
WITNESS ¢� J�6
TEST DATE I-G ' -5 I.6� 3 \/ 6
BEDROOM HOUSE
DESIGN
T.H.- r 1 T.H. * 2
—y[ EL ELEV.ELEV. NO
/ �, }✓ /v yi5 , ° \
h G 2 DISPOSER DISPOSER ` V�.
II PERC RATE MIN/IN. , \
�11 P� I L- 310.E FLOW RATE 330(GAL✓OAY) 1��VI'
SEPTIC TANK •3 ,. .. U���i=
Flo' REQ'DSEPTIC TANK SIZE
q�0 / `� i 't o
=jw
' LEACH FACILITY
SIDE WALLiol2rala._155 6c (2.5) • Q �` � G/D.
BOTTOM -"7�.5 ( I•p} . 78, G/D.
TOTAL .. Z66 sF ' S Carp ;I
o
!
- USE: Q 0 � /
LEACHING �T. I a I4 -
Fir
WATER ENCOUNTERED EE E' �� -0411
-
T'
Nf�TES'': (UNLESS OTHERWISE NO TIED) T!I•� )
1.DATUM(MSL)!.TAKEN FRO d�K), _
M�K
QUADRANGLE MAP I; 3 _
2.MUNICIPAL WATER AVAILABLE
3.PIPE PITCH:IIW"PER
4:DESIGN LOADING FOR ALL PRECAST UNITS:AASH0- -IO -.44: � � Of ��s // \ �v:
S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:I1)FT. ARM ARNE 8 I
i 6.PIPE JOINTS SHALL BE MADE WATERTIGHT �� H.
_....-
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. \
STATE ENVIRONMENTAL CODE TITLES CIVIL OJALA
1i
8. TW�b Pi.:►�l FoL.'P'r�Te�zs7 N0. � � � .. - .3 / .. \ ... ,1-•,
'fib '°Ec o 3 LF}}
I-tor �.E t��sC r-oL a7csC�`f �.vaG . cd.�n..►v LOCUS:
-
--
�p` PROFES �L EE
_ t_orlp 5t.-I vEY�
. .. .• Z � - � � 37 REF: '
e
_ -. . . PREPARED
Pa-- down cape- ng- Weer ng - _ R. �
ED FO
- CIVIL ENGINEERS,
BOARD OF HEALTH
LANosuR VEYORS -
CONTOURS (EXISTING).............
(PROPOSED)--O-O-O-O-- APPROVED DATE "`' MA : SCALP ,{
DATE g�; `��2
i'
SECTION SEWAGE
*9
w*
r w
-SEPTIC TANK- I : .: I r;1
�' D BOX - -LEACH 3
,TOP F ON .. r • *' ? �; �. ` �•` .
'.x ,. r..
( SL) "2"0F11eT04t"s
WASH
ED STONE
F-�
• 4 1 a
4.
IN-
OUT J '
IN OUT•.. IN• ,.� \ I?
TF
` a • G 3t'O.`T4- TANK 35.83
ELEV.
ELEV. ' ELEV. ELEV.
i..
Vrx�er 35�75 35,55 -o_T
ELEV. ELEV.
2�
, t \ \ 3
,a
WASHED STONE \ � \
_..TEST HOSE LOG. � 5I"J3 .. � ��
TEST BY -ri f�LS HA.6 , C�1-+ Lo l
•, L ��'/ 6
TEST GATE WITNESS 3 BEDROOM HOUSEI \
DESIGN "A
T.K r 1 T.H. +� 2 o u- 3j
-->,t ELEV. ,S - ELEV.
!I ; P.ERC RATE C 2 MIN/IN. DISPOSER DISPOSER { ;:. ; V 1 � E. o r
FLOW RATE 33.0 (GAL4DAY)
,
SEPTIC TANK - -
REQ'D SEPTIC TANK SIZE
�. LEACH FACILITY
SIDE WALL Io.�l2 1/ _155 4- �` � G/D..
m
a .�- ,_ t ; �,
BO*O'VI c� =7�,5 ► I.p}.• 7S, G/D: b`9
TOTAL .. Z6b.� 540
_ .
USE: Q I J � LEACHING
. 9
s
Io - ,
I f F �- n E�F.
WATER ENCOUNTERED 1•�—
rf
O
14
NOTES:' (UNLESS OTHERWISE NOTED)
T4 ,
1.DATUM(MSL):TAKEN FROM L � QUADRANGLE MAP
2:MUNICIPAL WATER - J►.VAILABLE g �"_ _ �� I ,. t A 1"P:._h .. X
IPE PITCH:%"PER
4:PDESIGN LOADING FOR ALL PRECAST UNITS:AASHO- -10 -44 nj
S..MIN.GROUND COVER OVERALL SEWAGE FACILITIES:(1)FT. . . H. �l ARNE fG �'S J
6:PIPE JOINTS.SHALL BE MADE WATERTIGHT !/ �' � -
I
7.CONSTRUCTION OETAILS TO BE ACCORDANCE WITH COMM.OF MASS. OJALA H ~'� \
STATE ENVIRONMENTAL CODE TITLE S CIVIL- OJALA SITE `
8. •r%:aa.� pL- - rr�C.4.:��� a.io �+-+ � LOC
us..�.0� # �/
-
� .PROF l EER
2Ec.�.o,w 51.•t v Yot✓; :+ REF:
: .. t
_
o�_ n cafe� `en .iaeeri� _ PREPARED FOR:-Al
�IG
R _
CIVIL-ENGINEERS,
BOARD OF HEALTH
CONTOURS (EXISTING)....:........
(PROPOSED) s, SCALE
LAND SU VEYORS
-0-0-0-0 APPROVED DATE - ��r'��'�' �`� MA �K ''.
- - - D ,TE oa.,
4