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2232 FALMOUTH ROAD/RTE 28 - Health
2232 Falmouth Road 71 Centerville A= 168 - 136 t IlII � UPC 12534 No.2�OR YAii1MaQ�.YM ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2 2 3 2 Fa 1 mo h Road �� /-77 ('antArvi 1 1 P Owner's Name:_ Doris Duffy _ Owner's Address: �2 o Date of Inspection:_ 2—09 G/—.0 J Name of Inspector:(please print) Wi 1 1 i am E_ • Rob nson Sr Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: ( s081 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CNIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails r Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health% DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of I0,000 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 time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t � � r Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2232 Falmouth Road Centerville Owner: Doris Duffy Dale of inspection: A V Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist.Any failure criteria not evaluated are indicated below. Co ments: Tys, itionally Passes: re system components as described in the"Conditional Pass"section need to be replaced or em,upon completion of the replacement or repair,as approved by the Board of Health,will pass. not determined(Y,N,ND)in the for the following statements. If"not determined"please The septic tank is metal and over 20 years old` or the septic tank(whether metal or not)is structurally unsound,a ibits 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 s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating hat the tank is less than 20 years old is available. ND cxpla' O servation of sewage backup or break out or lugh static water level in the distribution box due to broken or obstruct pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approv of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or teplaced ND exp ain: e system required pumping more than 4 times a year due to broken or obstuacd pipe(s).The system will pass in pection if(wvith approval of the Board of liealth): broken pipe(s)are replaced obstruction is n=vcd ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2232 Falmouth Road Centerville Owner: Doris Duffy Date of Inspection: 7-. L t-1— 0 6 C. urthcr 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 fail' to protect public health,safety or the environment. 1. yysem will pass unless Board of Health determines in accordance with 310 CMR I5.303(1)(b)that the ystem is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. iystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sys in is functioning in a manner that protects the public health,safety and environment: _ The system has a septic'tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a rivate water supply well•• Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other f ilure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2232 Falmouth Road Centerville Owner: Doris Duff Date of Inspection: •i �/ G D. Sy em Failure Criteria applicable to all systems: You mu't indicate"yes"or"no"to each of lute following for all inspections: Yes N - _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of cMuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow _ 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 I 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 front a private wain supply well with no acceptable water quality analysis.(This system passes if late well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that(lie well is free.from pollution from that facility and (lie presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no voter failure criteria are triggered.A copy of the analysis must be attached to this form.l (YeslNo)The system fails. I have determined that one or more of the above failure critcria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. L rge Systems: To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You usl indicate either"yes'or"no"to each of the following: (The oolowing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If yol have answered"yes'to any question in Scclino E cite system is—sidcred a significant ducat,or answered "yes' in Section D above the large system has fared.The owncr cr operator of wry large system considered a signi scant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMIZ 15.3 4.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2232. Falmouth Road Centerville Owner: Doris Duffy Date of Inspection: 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 t/ Were any of the system components pumped out in the previous two weeks? v Has the system received normal flows in the previous two week period? ZHave 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? V_ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no/ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 e Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2232 Falmouth load Centerville Owner: Doris Duffy Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):. Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x M of bedrooms): 3.�o Number of current residents: / Does residence have a garbage grinder(yes or no):�v a Is laundry on a separate sewage system(yes or no):LO [if yes separate inspection required] Laundry system inspected(yes or no): ?� ,D Seasonal use:(yes or no):k, Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5 - 2 6, 0 0 0 Sump pump(yes or no): x-p 2004 - 35, 000 Last date of occupancy: j-z-,t-_ 4 COMAIERCIA NDUSTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap esent(yes or no):_ Industrial ste holding tank present(yes or no):— Non-sani 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: + ' r�-a G ''.a 0.it z �- e e Was system pumped as part o the inspection(yes or no):_AZo If yes,volume pumped:_gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _✓✓Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contact(to be ob_tained from system owner) —Tight" Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Ic'i - $, Were sewage odors detected when arriving at the site(yes or no): 416 6 I'a6c 7 of I I OFFICIAL INSPECTION F0101—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEIVACE DISPOSAL SYSTEM INSI,ECTION FORAI PART C SYS UI INFORMATION (continued) Property Address:2232 Falmouth Road Centerville On'ncr: Doris Duffy Dale of Inspectlon: BUILDING E1VEIt(locate on site plan) Depdi bolo grade: Malcrials o construction:_cast iron _40 PVC_other(cxplaut): Distance CrIn private water supply well or suction lute: Cununcnts n condition of jowls,Vcnling,cvidcncc of Icakagc,ctc.): SEPTIC TANK: ,/(locate on site plan) Depth below grade: �—, Material of construction:�lconcWe_metal_fiberglass iol cal ter _oulcr(explain) -- y y 1C If tank is metal list age:_ Is age confinned-by a Certifica certificate) te of Compliance(yes or no):—(attach a copy of r Dimensions: Sludge depth: C.? Distance Gorr lop of sludge to bultun,of outicl Icc or bafllc: s Scum thickness:Q Distance from top of scum to top of outlet ice or bafllc: t Ll Distance from bottom of scum to bottom of outlet Icc or batllc: ) I low wcrc dimensions docnnincd: rb ��w v �)a 7 L�. Comments(on pumping rcconuncndauons, uilct and outicl Ice or bafllc condition, structurat intc6rily, liquid Ic%,cls as related to outicl invcn,evidence of Icakagc,etc.): GI(EASE TRAI': talc on site plan) Dcpu,below gfadc: Material of cons" tion:_cunctctc Inctal Gbcrglass_pulycutylcnc other (captain): _ — — Dimensions: Scum Ihickncs . Distance (roll top of sewn to tint of vutlel,cc or ba(lle: _ Distance Go t bottom of scull,to buttum of outlet ice or Ca—aj : Date of las pumping: Conuncn (on pumping tcconuncttdaliuns, inlcl and ourlct Icc or bafllc cunditiu:,, structulal integrity, liquid Idols as rclatc lu outicl invert,cvidcncc of Icakagc,cic.). 7 Page 8 of I I OFFICIAL INSPECTION FORA —NOT FOR VOLUNTARY ASSLSSMENTS SUBSUI ACE SEWAGL DISPOSAL SYSTLM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ProperiyAddress: 2232 Falmouth Road —Centervill Owner. Date of laspcctloo: -1,04-06 TIGHT or 11 WING TANK:_(tardc must be pumped at time of inspection)(locate on site plan) Depth below ade: Material of nstruclion:_concrete_metal fiberglass�,t,lyelhylclte othcr(cxplain): Dimension n . Capacity: allons Uesign FI w: gallons/day Alann pr cnt(yes or no): Alann Ie el: Alann in working order()•cs or no):_ Date of I st pumping: Conune s(condition of alarm and float switches,etc.): DISTIUBUTI N BOX:—(if present must be opencd)(locate on site plan) Depth of liq id Ievcl above outlet invert: Conuncnts note if box is level and distribution to oualcts equal,any cvidcncc of solids carryover, any cvidcncc of leakage in or out of box,ctc.). p I'UA1P CIIAN. EII:_(locale on site plan) Pumps in wo ing order(yes or no):— Alanns in w (king order(yes or no): _ Conunents note eondilion of pump chamber, cunditiun of pumps and appurtenances, etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2232 Falmouth Road Centerville Owner:Dc)ri s Duffy Date of Inspection: /7—;L SOIL ABSORPTION SYSTEM(SAS): z (locate on site plan,eacavation'not required) If SAS not located explain why: Type 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, etc. condition of vegetation, © 1- e4ieq ' -? le ` d S / h. L�' CESSPOOLS: esspool must be pumped as part of inspection)(locate on site plan) Number and config ation: Depth—top of liq d to inlet invert: Depth of solids I er: Depth of scum yer: ' Dimensions o cesspool: Materials of onstruction: Indication f groundwater inflow(yes or no. Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc): PRIVY: (locate on site plan) Materials f construction: Dimcnsi s: Depth o solids: Comm nts(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2232 Falmouth Road Centerville Owner: Doris Duffy Date of Inspection: r- 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 ent the building. J Y \ 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: 2232 Falmouth Road Centerville Owner. Doris Duffy Date of Inspection: 7—.;L 41 0 4, SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole within 150'/feet of SAS) Checked with local Board of Health-explain: i S 7 �/�1i I I r.r"' -Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you establishe the high ground water elevation: 's 7' �4 s o l s d/d?� . 3 oe,�1 11 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverseV/Zzj ❑Addressee so that we can return the Card to you. B. Recei d by(Printed N me) Dat o�fDeli0 Attach this card to the back of the mailpiece,or on the front if space permits. D. Is delivery address different from rem 1? ❑ 1. Article Addressed to: If YES,enter delivery address below: ❑ No v' o� �QLL.[� K (� 3. Service Type {y� ❑Certified Mail ❑ Express Mail QD� ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.O. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number i (transfer from service label) PS Form 3811,February 2004 Domestic Return Receipt - 102595-02-M-1540 UNITED STATE$PR k1� pa, "°w raM Ma�iY°'rm� ' # ostage USPS wow • Sender: Please print your name, address, and ZIP+4 in this box • PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE 200 MAIN STREET HYANNIS, MASSACHUSETTS 02601 Town of Barnstable FTHE 1p� do Regulatory Services snxrrsrnstE. ' Thomas F. Geiler,Director NAW9�p,E . A,�� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 12, 2006 Ms Doris Duffy 2232 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 2232 Falmouth Road, Centerville, MA,was last inspected on June 5th,2006 by, James D. Sears, certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Pit is full, not leaching—needs to be replaced. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health t . T COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m DEPARTMENT OF ENVIRONMENTAL PROTECTION h eq s�0v 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2232 FALMOUTH ROAD �J CENTERVILLE,MA 02632 Owner's Name: DUFFY,DORIS Owner's Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 -'� Date of Inspection JUNE 5,2006 Name of Inspector:(please print) JAMES D.SEARS ` Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 { ' CERTIFICATION STATEMENT -- I certify that I have personally inspected the sewage disposal system at this address and that the uiformat'1oV reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based bn my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority �- Fails Inspector's Signature: Date: 6-8-06 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments FAILED rt k R*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 e � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUNE 5,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUNE 5,2006 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: DUNE 5, 2006 D. System Failure Criteria applicable to all systems: ✓ You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than%day flow �— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUNE 5, 2006 Check if the following have been done. You must indicate`yes" or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No If Existing information. For example,a plan at the Board of Health. If Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CNM 15.302(3Xb)] Title 5 Inspection Form 6/15/2000 5 j Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUNE 5, 2006 FLOW CONDITIONS RESIDENTIAL,/ Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2004—35,000 GAL/2005—26,000 GAL Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A—NOTE:SYSTEM PUMPED AFTER INSPECTION. Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1986 PERMIT#86-100 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: RUNE 5,2006 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 20" Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting;evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 22" Material of construction: _ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000-GALLON PRE CAST. Sludge depth: 8" Distance from top of sludge to the bottom of outlet tee or baffle: 22" Scum thickness: 4" 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: 14" How were dimensions determined: ASBUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL,TANK&COVERS AT 22"INLET TEE—OUTLET BAFFLE. TANK TO BE PUMPED AFTER INSPECTION. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete e metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUKE 5, 2006 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (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.,): D-BOX NOTED ON ASBUILT,LOCATED ON SITE. BOX IS 3'BELOW GRADE—NOT OPENED. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 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: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUNE 5, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE(1)1000-GALLON PRE CAST PIT. PIT IS 64"BELOW GRADE WITH COVER AT 19"PEPE INTO RISER. PIT IS FULL,NOT LEACHING—NEED TO REPLACE. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2232 F.ALMOUTH ROAD CENTERVILLE, MA 02632 _ Owner: DUFFY,DORIS Date of Inspection: JUNE 5. 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benelunarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ONI c / 1 O Title 5 Inspection Form 6/1 i':.000 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: 2232 FALMOUTH ROAD CENTERVILLE,MA 02632 Owner: DUFFY,DORIS Date of Inspection: JUKE i, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole wnthum 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: G ,Fa/ Z 1� Qo�r� 0 10i Title 5 Inspection Form 6/15 2000 11 q - No.._`.....�........... Fimic.............................. rp THE: COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF %� ............................ Appliration for Dispatial Works Tonotrurtion 1hrmit Application is hereby made for a Permit to C nStruct (tll�®r Repair an Individual Sewage Disposal System at: Z ;), "4 W . ................ ...774 M .1 . 0 Z!R)...... ............. .... .................................... ----- ------- 0, Eqcai.n�'dress e N 0— .... ... ... n r ner Address .......... ......... Installer Address Type of Building Size Lot;2-/ _D ........Sq. feet U ,1 Dwelling—No. of Bedrooms........ ................................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons.__.-___-_.__-_________._._. Showers Cafeteria Otherfixtures ..................................................................................................................................................... WDesign Flow.............. :____.____._....___.gallons per person per day. Total daily flow_..,.,�. ../?...........................gallons. V4 Septic Tank—Liquid capacity/!!�_U.gallons Length.4-f.. 4."'.. Width._. Diameter________________ Depth..K.."J?_" Disposal Trench—No_.................... Width_...__...___.-____ Total Length.................... Total leaching area____.___...._. sq. ft. 0 - ----- Seepage Pit No--------------------- Diameter_:._.. Depth below inlet--G ....... Total leaching area.._j��.MIJ ....stft� Z Other Distribution box Dosing%rnk ( ) �, 0-4 . _.1 -0 —14�4 Date___ 17 /Y Percolation Test Results Performed by..... A0_4M ....... Test Pit No. I.......5.7..--aninutes per inch Depth of Test Pit__. Depth* to ground water_ _ Test Pit No. 2................minutes per inch Depth of Test Pit______._----___..... Depth to ground water........................ .................. ......... ................. ....................................................... ...................... I 41 0 Description of Soil............................ ...........— ........... .................................................... ...... ........ ..................... U ...... ....... 71&9).1 .................................. Z ......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with agrees n the provisions of TL I TAIE 5 of the State Sanitary Code—.The undersigned further Ds not to e the system in not to oper on until a CertifigKte of C ce has been d b the b and f health. Ague y gar n -7 ------ ...... -7 D tu;!/, .......... ............... �p &Ve 0 D DDrov v.... ........... . ... ..... ..... ................. Application Approve By.............................. .. . ..... ...... . p .. ...TZ)..._...- ate Application Disapproved for the following e ons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo..... ......1.2-Q----------------------- Issued.- - -------•---- ................................ Date ------------—------------------------ ------------ -------------- ------ • r'3 L �.� No......................._ Fps............._.... _. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.....................-.................. .-....... Appliration for Disposal Works Tonstrur#ion rrrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....:...........--.............................................................................. ......._.._.....---•...--•.....----•-•....._....-••--•••---....._......---....-..---............. Location-Address or Lot No. ......................».......................................................................... •-•-...-•-••---•--•••-_._....................•--•.....—.......................................... Owner Address W Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers a YP g ------------------------•--- P ( ) — Cafeteria ( ) a' Other fixtures .-•-•.............................•-._......... ---------- ..•-••••............. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-------------------- ft. 3 Seepage Pit No............:........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by--••••....................•__.._....-•-•-•••...._--•-•-----...------•-•_. Date................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••--...•--•-------••--••--•--•................................ .•-••--•••-----•.----------- -•-•.--------- ••---•------------.----.....-------- •--------- 0 Description of Soil......................................................... W V ...........••••••-•••--•-•--••-•-.......•-••-----•---•-••..................•-••••--••-----•---••-•-•••---...--•••••------•-•••--•-•-••-•-....... ......_.......................••............•-•----- W .---------------- ------------------------------------- •............ U 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 TITLE 5 of the State Sanitary Code The undersigned further agrees not to ce the system in opera on until a Certifi to of Co li nce has been issued by the board of health. gne .............................................. t yc. K.... �D Application Approv By................................. ......... ... .. ...... --^ -^-•--- --.D to ------------- Application Disapproved for the following r,a.�ons:...........................•......_.........._.__._____.__................__.__......__.___..._...........-__ ----•-•--•---••--•----••-•----•-•...............•---....----------........------..._...-••-•._...•--•......•--•--•-•••••-•-•••....•---•-•......._....-•-...•-•-•--•--......-•----•••••--•....---...-•---- Date PermitNo...................................................---- Issued.................................•-------•-•---...._.... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NJ 01,rrfifirate of Toutvhanrr THIS IS TO CERTIFY, That the dmilividual Sewage Disposal System constructed ( ) or Repaired ( ) by.................. F�-z?, -....... —..�..� c� :4c..-..-....................•---•-•-----•-•-•-----------••-----------.--. -----_ .Ins at_......•••••�----_4 ............................--_...•.. �p ` n o - -1��......�..............•---.....----•-............•......_...-. ................... has been installed in accordance with the provisions of TI F 5 of The State Sanitary Code a desc ibed in the application for Disposal Works Construction Permit No.___.��_�_�--.7.-a__-___- dated--- ----- -------------.-•-•.------- THE IS SUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTE CT ON SATISFACTORY. DATE.... K L - -- - ......_ Inspector.. ............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ............. No.... Fim........................ Disposal ot�o Tonstruf4fint Vrr Permission is hereby granted... ���-at --V1�-•-- -- )..... to Construct ( or Re it ) an In 'vi u Sewage Di�jo System�� Street 1 0 as shown on the application for Disposal Works Construction Permit No.... ............. Dated . _. 2. ..7�.3 .......... oard of Health DATE.-------••••••••..._S_.. �'• 96._.....-•---••-----•....•••...... FORM 1255 A. M. SULKIN, INC., BOSTON IiASSESSOR'S MAP NO. ( ' PARCEL ANW, LOCATION RL"[WW A E PERMIT NO-4 Lo 7- VILLAGE INSTALL R S INA7/, & ADDRESS f U I L D E R OR OWNER DATE PERMIT I SU D DAT E COMPLIANCE ISSUED \V 96 i H s£ 9 I ! I � —1 '� --,---.-,�I,.-,, - - - I "' - � - , - I �,-71��ll.;l---"------,--7---�--77!'-- ,-'�-��--7-7------ - - r, , --,� - -�-,-" - I - , � 7 1,711.-7 ---7777� , I,� - , �,�, ��5,1� � 11 I , . � . -I -�l I I- �- , - - �,,-1 -�- , :.,;,':7:��,:--"�,� - . 1-7- --7-,. , � ,%-�-,-� -, - 11 : i ,� ".1�,I �' I �� ',-,* '�,- - -_: , - ; � , � _:-� -� ,- - I : I I , 1� - � I�1- !�, I . 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