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Home My WebLink About0201 FIVE CORNERS ROAD - Health PF 201 Five Corners Road Centerville A= 168 - 069. UPC 12534 IN*.2.153LOR No. . D �� 10-a, r 4f Fef$100.00 THE COMMONWEALTH OF MASSACHUVETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r applicatton for 33i5pogal 6p5tem Conztrurtton VICrmtt Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 4 2 8—9 3 5 2 201 Five Corners Rd, Centerville Joseph Grant Assessor'sMap/parcel 168/69 201 Five Corners Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8.9 4 Wm E Robinson Sr Septic Eco-Tech Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder 1(0) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Eco-Tech, ETE-242 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of ea] . r g Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons ��// r Permit No. ' ZU- • Date Issued O No. A_rt' IU � Entered in computer: THEC,Q,MMONWEALTH OF MASSA'C O'S�TTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS •- i:� - ZIppYication for nigonl *p!5tem Con5tru.0ton Permit Application for a Permit to Construct( ) Repair(? Upgrade_( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 4 2 8—9 3 5 2 201 Five Corners Rd, Centerville Joseph Grant Assessor'sMap/Parcel 168169 201 Five Corners Rd, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8.9 4 WMUE Robinson Sr Septic Eco—Tech PO Box 1089., CentervilleCentprville 43 Triangle Ci.r, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder TIO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system .to plans of Eco-Tecft,m#ETE-2424 i Date last inspected: Agreement: ~ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of.. Compliance has been issued by this Board of al . Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons cob —Permit No. GT 7 Date Issued ( I ----------------- THE COMMONWEALTH OF MASSACHUSETTS Grant BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( X) Upgraded ( ) Abandoned( )by Wm E Robinson Sr Septic Service at 200 Five Corners Road, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Q 0(fl t�G� dated 9 Installer 22 `D1 emu, Designer #bedrooms ®, (0 Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will fun ion as de\si.ane Date ( [ L. Inspector ———————————————————————————————————————————— No. d L)Oa $490.00 Gran THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS .. 0i!9po.5ar,*p5tem Con5truchon Permit Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( ) System located at 201 Five Corners Road, Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be o)mpleted within three years of the date of thispermit. Date l 1 p Approved by\ , Town of Barnstable Regulatory Services Thomas F. Geiler, Director - a�tnsr.+esE, • 9� HAW. g Public Health Division pIEDMA�� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: S�p t l q, 100�' Designer: Cd V C"r ht4()W Z P 5. Installer: (S YI�� ✓ Address: 43 TRIWGL,C C12CLC Address: S�NOWIet�. Mq 025�� On / ' � J b ' 3-6 w was issued a permit to install a (date) (installer) septic system at F11 ve Corners based on a design drawn by (address) p g u i 0( � �i 0*4`10k - �ZS dated sC-p-e vn b err J (designer) J I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. t/ I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. 9 DAVID cyG� o D. a GOUGHANOWR N (Installer's Signature) No. 1093 SgNITAR\PN 6� �s (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 4 TOWN OF BARNSTABLE LGCATION I �lU� �� SEWAGE# V,,JLLAGE LQ(��i�r'y,1/e_ ASSESSOR'S MAP&PARCEL /4'a b 06 INSTALLERS NAME&PHONE NO. Ot J7p o oyV SEPTIC TANK CAPACITY MO V LEACHING FACILITY: (type)E— ni 64 (size) 7-# NO. OF BED/ROOMS OWNER s PERMIT DATE: '[ COMPLIANCE DATE: O Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist '.: within 300 feet of leaching facility) Feet FURNISHED BY �ry e Town of Barnstable P# Va 7 Department of Regulatory Services / Public Health Division Date 1639 �� 200 Main Street,Hyannis MA 02601 ' � rF0 Mla Date Scheduled Time .. Fee Pd. 60 Soil.Suitability Assessment for Sewage Disposal ' Performed By: r/�Ut� �� t1'�� lNl�- Witnessed By: - p �-'�^ LOCATION& GENERAL INFORMATION Location Address 2Z I 19 Ft Ve Cor0 ers . R � Owner's Name a o�epM 1,4 fi 6e4 V1 e I ( Address �I U c 1 cp r h N ry Assessor's Map/Parcel: C 6TJ`6"I ~Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Rec,i4edlr`-'fd Slopes(%) 2�(? Surface Stones Distances from: Open Water Body 10 0 fi ft Possible Wet AmajLL)±,' ft Drinking Water Well ft Drainage Way "0 ft Property line 0 'k ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands to proximity to holes) Tp, i1 1 ,,n 1 / GROUNDWATER ADJUSTMENT i I EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. j �zQPO INDICATED GW 16.00 NOD EX WELL AAIW-230 READING DATE AUG. 2006 READING 22.7 GO I ADJUSTMENT. 2.9 f ADJUSTED GW 18.9 F �=_. ar,�u! d(�1.I "l 5"JDepth Parent material(geologic) to Bedroc l- Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face ! Estimated Seasonal High Groundwater Sep ahpre w° DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Set?, r4100dP Depth Observed standing in obs.hole: _ In, Depth to soil mottles: Depth to weeping from side of obs.hole: __ In; Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor— Adj.Oroundwater level,, _ PERCOLATION TESL' Matt;9114106 TIMe it1 —16 Observation Hole# ^ i Time at 9" Depth of Pere 7b i H Time at 6" Start Pre-soak'ISme @ (015 TSme(9"-6") ALq-- End Pre-soak v`' 51 Rate MinJInch 2.V11 p) Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning: Q:\SEPT[CIPERCFORM.DOC 'SOIL TEST LOG DATE OF TEST: SEPTEMBER 14, 2006 SOIL EVALUATOR: DAVID D. COUGHANOWR. R.S. WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. NO TEST PIT 1 PAARENTUNDWATE MATERIAL: PROGLACIRALD OUTWASH + ELEVATION = 42.25 +- PERC AT 62 in 2 MIN/INCH IN C SOILS f t DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING j 42.25 0-4 0 LOAMY SAND 10 YR 3/2 NONE FRIABLE l 4-9 A LOAMY SAND 10 YR 3/4 NONE FRIABLE 9-34 B LOAMY SAND 10 YR 4/6 NONE LOOSE 39.42 34-120 1 C MEDIUM SAND 1 10 YR 5/4 1 NONE LOOSE 32.25 NO TEST PIT 2 PAARENTUNDWATER MAATER AL:ENCOUNTE PROGLACA LED OUTWASH PERC AT 62 in 2 MIN/INCH IN C SOILS ELEVATION = 42.20 +- DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 42.20 0-5 0 LOAMY SAND 10 YR 3/2 NONE FRIABLE 5-11 A LOAMY SAND 10 YR 3/4 NONE FRIABLE 11-26 B LOAMY SAND 10 YR 5/6 NONE LOOSE 39.87 26-128 C MEDIUM SAND 10 YR 6/3 NONE LOOSE 31.53 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. Flood Insurance Rate Man: ' Above 500 year flood boundary No— Yes , Within 500 year boundary No Yes Within 100 year flood boundary No '� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 8S If not,what is the depth of naturally occurring pervious material? Certification I certify that on VJ Od q 95 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the requirearcing,ex rose and xpe fence described in 310 CMR 15.017. Si n ture � Date Se _i 14, 006 Q:\S.EPnCVERCFORM.DOC Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi r; Owner Owner's Name ,/ information is Centerville Y MA 02632 May 31, 2016 required for every page. City/Town State Zip Code Date of Inspection (V 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:When filling out forms A. General Information on the computer, ` cv use only the tab 1. Inspector: c, , key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response �y Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F g� ��ati N e Local Approving Authority D. CO A OWR N 9345C May 31, 2016 Inspector's Sig re `�cfSTEa�bmit Date SqN! R The system insp a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a.design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corner�Woad -Assessor's Map 168 Parcel 69 Property Address t: James and Maryi�u Pierozzi Owner Owner's Name "` information is required for every Centerville MA 02632 May 31, 2016 _. page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," explain. lain. P P 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.com'plying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it isstructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than20years old is available. ❑ Y ❑ N ❑ ND (Explain below):,; ^ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31 2016 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N .❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy iswithin 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r ' r Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31 2016 required for every - y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: . **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent_and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31, 2016 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. I For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name - information is required for every Centerville MA 02632 May 31, 2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31 2016 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ., r, N Yes ❑ No Water meter readings, if available last 2 ears usage 134 gpd 9 ( Y 9 (gpd)) Detail: 2014: 38,000 gallons 2015:60,000 gallons Sump pump? ❑ Yes ® No � Last date of occupancy: currentDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address _ James and Marylou Pierozzi Owner Owner's Name information is required for every- Centerville MA 02632 May 31', 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner Was system.'pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was Y uantit pumped determined? q Reason for um in : p p 9 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31, 2016 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 9+ years. Certificate of Compliance for a new system was issued 9/18/2006 (Permit#06-402 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, listage: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 4 in t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 201 Five Corners Road Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is required for every Centerville MA 02632 May 31, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31 2016 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete - ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is required for every Centerville MA 02632 May 31, 2016 page.e. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert 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.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ElYes ❑ 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31, 2016 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ Teaching 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 8 inches below the top of the peastone layer. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is required for every Centerville - MA 02632 May 31,2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31, 2016 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties 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 FgVE CORNERS ROAD W WCr > z LOo CA TDO#VSS CC NOT —OF SEPTIC COMPONENTS Q o TO —DISTANCES IN DECIMAL FEET 3 SCALE -A B C r 1 ——— 26 17 A 2 67 22 ——— EX§S T§NG 0 2 D—BOX 20 tiL ` •• LEACHING GALLERY B C I 1000 GALLON 508 364-0894 SEPTIC TANK THIS SKETCH IS BEST VIEWED IN COLOR FORMAT QOq D t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is required for every Centerville MA 02632 May 31, 2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ 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: 9/18/2006 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system is over 5 feet above high groundwater. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road -Assessor's Map 168 Parcel 69 Property Address James and Marylou Pierozzi Owner Owner's Name information is Centerville MA 02632 May 31 2016 required for every y page. City/Town. State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE PRECAST DRYWELL BOTTOM OF LEACHING PER DESIGN PLAN LEACHING IS ABOVE HIGH GROUNDWATER Y W 0 N GROUNDWATER ELEVATION PER GIS MAPS t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road --- --- ----- ------ -- -- ---- ------ - ----- --- ---Property Address Kathy Duffley Owner ----------- ------------ --- --- - -- - — -- Owner's Name -- information is required for Centerville - MA 02632_ Ju;y 12, 2013 every page. CitylTown 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. General Information n Whhenenfilling out. forms on the computer,use 1. Inspector: only the tab key �8 ®o to move your Patrick M. O'Connell cursor-do not —use the return Name of Inspector key. Septic Inspection Services Co. Company Name ------- ------ --- _._... - - -..._ ---- -- -------- --------,..--------------- C111 PO Box 1487 Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508.428.1779 SI 12855 --- -- ----- _ -......---------- .. --------- -----— --- -- --Telephone Number License__ Number B. Certification - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper 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 ❑ Conditional) Passes ' Y ❑ Fa:c Zzz ❑ Needs Further Evaluation by the Local"Approving Authority 32 July 12, 2013 Jgb# 13-60'•? _. - -- F - ----Inspector's -- - Signature — - - Date ` „ --- C rn The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 4 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 . Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address Kathy Duffley Owner - --- --- -- - ------------- Owner's Name -- information is Centerville _ required for MA 02632 _July 12, 2013 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection, leaching system showed no evidence of surcharge or saturation. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the 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): t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address ------ " - ----- Kathy Duffley Owner Owner's Name --_- - — -- ---- -- information is Centerville required for MA 02632 July 12, 2013 every page. Cityfrown State tale- --------..__.. Zip Code Date of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): F, 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 o1,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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 5 P p y 0 feet of a bordering vegetated wetland or a salt marsh 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address ----------_-- _--------..._._------------ Kathy Duffley Owner - --- ---- Owner's Name -- -- information is y required for Centerville MA 02632 Jul 12, 2013 ____— _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water ` supply well. 0 The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ---------- — ----------------------- * This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspecons: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3113 Tale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessmentr, — 20a,.•'"� 201 Five Corners Road Property Address Kathy Duffley Owner Owner's Name information is required for Centerville __ _ __ MA_ 02_632 Jul 12, 2013 _ _ every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggerej. A copy of the analysis and chain of custody must be attached to this form.] ❑. ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking watei supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address - - Kathy Duffley Owner Owner's Name ---------- --.._.. -- ------- ---- information is required for Centerville MA 02632 _ July 12, 2013 -------- _------ ----- every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health 1 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: + Number of bedrooms (design): 3 -- Number of bedrooms (actual): 3 -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 — t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address -- --- ---------------------------- - ------ -- Kathy Duffley Owner Owner's Name - -- -- --- -- — — information is Centerville MA 02632 Jul 12, 2013 _ required for ____ y every page. Citylrown State Zip Code Date of Inspection D. System Information Description: 1 Number of current residents: - --------- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 58,000 gal. _ 9 ( Y 9 (gpd)): 79 gpd. Detail Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Industrial Flow Conditions: Type of Establishment: ------- ---- ---- --- Design flow (based on 310 CMR 15.203): -- ----------------- -- -------- - Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): ------- — -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address ------------—---- --- —--- Kathy Duffley Owner Owner's Name ----- ---- ------ -- information is required for Centerville — — __ MA_ 02632 _ July 12, 2013 _ every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: - — Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped three weeks prior to inspection. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: --------..--- _ gallons How was quantity pumped determined? ----Reason for for pumping: --- -- ----------- ---- -- Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): (Sins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 201 Five Corners Road ------------------------------------ - Property Address Kathy Duffley Owner Owner's Name ------- — — information is required for Centerville _ _ _ _MA_ 02632 July 12, 2013 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of;nformation: Leaching system installed 9/18/06 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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.). Septic Tank (locate on site plan): Depth below grade: 16" 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: 8.5' long x 5.2'wide - 1000 gal. Sludge depth: 0,.--__ t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 201 Five Corners Road Property Address --- — Kathy Duffley Owner Owner's Name information is required for Centerville — __ MA 02632 __ July 12, 2013 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle - -- 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 Measured 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 had liquid only, no solids. Liquid level was found at bottom of outlet in-vert. Grease Trap (locate on site plan): Depth below grade: reel Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Dale - 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address Kathy Duffley Owner Owner's Name -- -- - information is y required for Centerville MA 02632 Jul 12, 2013_ every page. Cityrrown State____ Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: ----- ---. - —_ Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ------------ — ---_— Capacity: ------ - — gallons Design Flow: gallons per day -- Alarm present: ❑ Yes ❑ No Alarm level: — --- --- — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address — -- Kathy Duffley Owner Owner's Name -------------------.-.----- information is required for Centerville — MA_ 02632 July 12, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 1.- --- _ 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.): No solids or high stains present. Liquid level was at bottom of outlet pipes. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 201 Five Corners Road Property Address ------- ----- Kathy Duffley _ Owner Owner's Name ----- — — information is Centerville e required for MA 02632 Jul 12, 2013 -------------- every page. ity/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: Two 500 gal® leaching chambers number: drywells. ❑ 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.): SAS was probed with no evidence of saturation found. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert ------------___.—..._.__ Depth of solids layer --— Depth of scum layer --- _— _—. Dimensions of cesspool Materials of construction _.------__.______—_--.—__ Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 201 Five Corners Road Property Address — -- Kathy Duffley Owner Owner's Name -------------- --------- information is required for Centerville MA 02632 every page. Citylfown ----- _____ JU,7�12, 2013 — State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids ---- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments <«;74 201 Five Corners Road Property Address Kathy DuffleY_......._._.. Owner Owner's Name information is Centerville MA 02632 Jul_ 2 2013 required for _ .-.__...._ ._ ...._..._ ..._.......__. . - State Zip Code Date of Inspection every page City/Town ----------D. System Information (cont.) Sketch Of Sewage Disposal System. Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or 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 f l rimvvinn attar.hPrl SPnaratPly 1 Front Five Corners Rd. 67 17 rk 22 ..:; 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 201 Five Corners Road Property Address ---"-- -- Kathy Duffley Owner - - -- -------------- -..--------- Owner's Name -- - information is Centerville required for — _MA _ 02632 _ July 12, 2013 _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20+ 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: pace ❑ 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: USGS topo map. You must describe how you established the high ground water elevation: Topo map shows property Considerably hhigher than all ponds in area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.w 201 Five Corners Road _ Property Address - Kathy Duffley Owner -- --- -- ------ -- ------...----- - Owner's Name information is required for Centerville _ MA 02632 _ July 12, 2013_ every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information - Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE ' CATION 1& f ' SERE# ✓�S t° "PII,I;AGE ✓JI i.Q ASSESSOR'S M4P&PARCEL �'S NAME&PHONE NOcsy�oC SEPTIC TANK CAPACITY Qp LEACHING FACILITY:(type) _�(size) �� NO.OF BEDROOMS OWNER PERMIT DATE: C ATE5� I�� I l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on:` site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Front t \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ♦ . ! f ! f i ! f f f / ♦ ! / l f / f f r , f f r f f , f f r J f f , f ! J f ! f r ♦ ♦ r . 'Five Corners Rd. ♦ f / I / .+ f ! f / I f f f. / ! f f / I / f r f f , ! ♦ f , f r f , f t 67 ! f f f J ! ! ! 17 22 26 N Y'�N 4 CONTOURS DUTE R ' - t - - - - - - - `FA�MDUTH ROAD 0 -EXISTING 50 gTER �F MINIMAL GRADING PROPOSED <G WESTMIN eo BENCH MARK ESTT 3mF READ Locus PK NAIL IN ROAD ELEVATION = 39.50 BARNSTABLE GIS DATUM /51 CENTERVILLE. MA LOCUS MAP NOT TO SCALE 20-0 444 E \ •� LEGEND - � \ `` EXISTING FA O TP 1 \ SEPTIC TANK 18 l D ROB 20 �£ o-BOX ❑ wEL L ING M O TEST FIT / EXISTING O LEACH FIT l Z \ 24 FL x 12. f t x 2 FL I UTILITY POLE � ' LEACHING G LLERY m �?� \1 TREE +15F -NUMBER REFERS TD TYPE ///�4� DIAMETER IN INCHESLDT 11 / OEOAK RM--MAPLES P--PINE �w �W A REi\= 16586 s f+- 42 46 44 / r F 64. / SEPTIC SYSTEM AS BUILT PLAN WA jj�� \ �'� GA TER Teo -TO SERVE EXISTING DWELLING 46 GAS /: JOSEPH & CONSTANCE GRANT EST. GATE '�P EMENT A D OWNERS OF RECORD OF �I CORNERS ROAD FOG 0 � 201 FIVE 1995 �' ZNOFMgS �� CENTERVILLE. MA e R ��FA�' sq�y �ON�� PROPERTY ADDRESS N E o DAVID s � D. -a 43 TRIANGLE CIRCLE ASSESSORS MAP 168 PARCEL 69 FLANoC)p 8 COUGHANOWR N SANDWICH MA 02563 PLAN BOOK 235 PAGE 55 . No. 10935J8 364-08J4t�J� o DATE. SEPTEMBER 19. 206 IVE SCALE: 1 in- _' 20 FL GISTS. -ioa #E T E-2 4 2 4 PAGE I OF 2 VERSION.• 20 0 20 40 N17 LPN PIS THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM 1 DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING 0 10 20 SeP f �� 2DD� PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER r SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. r � 3