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HomeMy WebLinkAbout0063 FULLER ROAD - Health 63 Fuller Road Centerville P 188 127 AW UPC 12543 No. 53LOR ►,acr,Yaa Yw No. �®�� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9ppf ration for Misposal *pstrm Construction 3permit Application for a Permit to Construct( ) Repair(,Upgrade( ) Abandon( ) ❑Complete System e Individual Components Location Address or Lot No. (P J Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 0 -�7 16 z;A-9-PA f Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: 3 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ilk gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ®D 66 01 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when appli able) 6l � yfT CmA aT . ov1VD 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 ftea Signed Date O WzlQ Application Approved by Date -2 r�r✓ Application Disapproved by Date for the following reasons Permit No. d 2—G Date Issued '' No. G GO Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: '. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS " Yes r° Rppli.Lation for Misposal &pstrm Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System -' ndividual Components Location Address or Lot No. /„2 (� �(J� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ka 7 L�N m r 1 1/6- ejb5-PA f t— tr Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Jj Type of Building: 506-7,7f-cl7 ' D.w gz No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' z Design Flow(m�n required) ,r", gpd Design flow provided A gpd r Plan Date Number of sheets Revision Date . - t N* Title ] jSize of Septic Tank /0�a j�S�IV100) Type of S.A.S. '7:)/'1— v Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 Ott T" a�� D 3 t Date last inspected: Agreement: r• 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 systemain operation until a Certificate of Compliance has been issued by this Board of Hnneatth. Signed r `�(l ivl M Date Application Approved by T'x!� „ A , Date 2 ��v � - Application Disapproved by Date " for-the following reasons Permit No. d - 2 p Date Issued �[1 THE COMMONWEALTH OF MASSACHUSETTS p,f BARNSTABLE,MASSACHUSETTS 1' Certificate of Compliance J' THIS IS TO CERTIFY,that_theOn-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by -,AN�€>� /.fl�l1a�V tTI tYV - - at (/ �� , has been constructed in accordance with'the provisions of Title 5 and the for Disposal System Construction Permit No. 0-_ C dated Installer 7 TrA/v` Designer #bedrooms Approved design flow AV* gpd i The issuance of this permit shall not be construed as a guarantee that the system will fanctiof,as destjed.DateInspector /t 1i /C f. r No. �0 2 - , .� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS -Misposal 6psteConstruction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at //► 3 1'f;//-E-IL 2�, ✓r Jr . and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m/must be completed within three years of the date of this permit. Date v Approved by Vln i Commonwealth of Massachusetts ip Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 63 Fuller Road V� Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville y MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road I�SI Company Address Teaticket Ma. 02536 City/Town State Zip Code »� 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 09/03/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. 63 Fuller Road u� Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 3 bedroom home has an H-10 1000 gallon septic tank feeding a precast leaching pit. At the time of the inspection the leaching was dry and no visible failure criteria was found. The pipe from the septic tank to the leaching pit was replaced as part of the inspection. A permit was pulled for the repair. All covers are raised to within 6" of grade. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is Centerville MA 02632 09/03/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 r Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33 plus GP Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage Town water 9 ( Y 9 (gPd))� Detail: In 2019-180,000 gallons were used and in 2018-448 000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road V Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 52"feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and it came freely. NOTE-The bathroom in the basement feeds the septic tank by gravity. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 46"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: H-10 1000 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts i�p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road V� Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): i Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I Commonwealth of Massachusetts ,p Title 5 Official Inspection Form `b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road V� Property Address Adrian and Connie Gaspar TTEES Owner Owners Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 5Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road V� Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer I Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a� 0 Deck H L A B A B 1 19' 33' 2 25' 37' I� 3 38.5' 23' Q a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts p. Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14' plusfeet 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 63 Fuller Road Property Address Adrian and Connie Gaspar TTEES Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ECOJECH Environmental www.eco-tech.us THIS FORM I$A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/1512000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 63 Fuller Road Centerville Owner's Name: Stanley Smiley Owner's Address: 142 Perkins Street Melrose.MA 02176 Date of Inspection: August 18,2004 N'c`UM of Inspector: (Please print) David D Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43'Trianele Circle Sandwich,MA 02563_ Telephone Number. (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails -------------------------------- ----- ------------------------ Inspector's Signature Date: AyovS* l$, ?l* The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.-If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note=-> A septic system is deemed to pass this Real Estate Transfer Inspection lfit does not trigger any of the failure criteria listed below. 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. ****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 l ' d N H ' ON saainaaS 82e21aON P98dS�y2 ! 1 fNd1o: G b007, 1 daS Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 1.8,2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5 303 or in 310 CNM 15.304 exist Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health will pass. Answer yes, no, or not determined(Y,N,or 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 stnxturally unsound,exhibits substantial infiltration or enfiltration,or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or higIi static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.The 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 four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain . 2 £ ' d Z M IO N S801AJOS 82e2jJ00j P88dS�y2!1 WdL0 : 0 tr00Z ' L d@S I Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Fuller Road Centerville Owner: St_ anley Smiley Date of Inspection: August 1.8,2004 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 and 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 pri`ry is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will frul 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 Itas 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ainmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm provided That no other failure criteria are triggered.A copy of the analysis must be attached to this form 3)OTHER 3 t ° d 7GfRION SeOinaeS e2e2;a,ON peedSjy2 ! 1 lNdL0: 9 ti00Z ' L ° deS i page 4 pf 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Faller Road Centerville Owner: Stanle Smile Date of Inspection: August 18,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions east as described in 310 CMR 15.303. The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool, X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool, X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool, X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of fire SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XC Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis-(This system passes if the well water analysis, .perfornied by 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 limn 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form) No (Yes/No)The system hails,I have detennined 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 gird 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 y 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. 1f 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 wider section D shall upgrade the system in accordance with 310 CNM 15.304.1"he system owner should contact the appropriate regional office of the Department. 4 G 7.GRRION SHIAJO�q 82F2110W p88dRjg2lI NRO : G M 7, l ' daR Page 5-of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18,2004 Check if die following have been done:You must indicate either"Yes"or"No"as to each of the following; Yes No Y T pumping information was provided by the owner,occupant or Board of Health, N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? Y Were all system components,excluding die SAS. located on site? Y i Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for die condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum'? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on dhe proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECILUS The size and location of the Soil Absorption System(SAS)on the site has been determined based on: N Existing information.For example,Plan at the Board of Health. Y _ Determined.in the field(if any of the failure criteria related to pan C.is at issue,approximation of distance is unacceptable) [310 CNM I5.302(3)(b)] 5 q ' d 7.CFR ' oN S831A)8q 82E21aoN p88dU011 fNdRn : q tnN 1 ' e.S Page 6.of 11 OFFICIAL.INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August l$.2004 FLOW CONDITIONS RESIDENTIAL Ntunber of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health De t Number of current residents 0 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no :(If yes,separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): 1 gpd Sump Pump(yes or no): no Last date of occupancy: about 6 months ago COMMERCIALANDUSTRUL: Type of establishment: Design flow(based on 310 04R 15,203):: gpd Basis of design flow(scats/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: S stem not Rumped in recent.Dast Real Estate agent) Was system pumped as part of the inspection:(yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank dism4butien beAt,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternate technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age:about 32 years System is asstuned to have been installed in 1972 at time of dwelling's construction Were sewage odors detected when arriving at the site: (yes or no) no 6 ' d 70RR ' ON SOOIAaaS 82E21)ON paadSju2il AdRO : G V007 l ABS Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner; Stanley Smiley Date of Inspection: August 18 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 3 ft Material of construction. X cast iron _40 PVC_other(explain) Distance from private water supply well or suction lhie 20+ Comments:(on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears amcl ually sound A blockage was discovered and client arranged to have sewer line cleared, SEPTIC TANK:Yes (locate on site plan) Depth below grade: 30 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum tluckness: . 2 in Distance from top of scum to top of outlet we or bale: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to top of tank Comments:(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Putn i ig not re uired nt thus rime but maintenance pumping is recommended within and eve 2 ears. Li uid le el at outlet invert.Tank and tees appear stntcturally sound and fitnctionin�as intended No evidence of leakage in or out GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction: concrete_metal._ fiberglass,polyethylene other(explain) Dimensions, Scum thickness: Distance from top of scum to top of outlet tee or bade: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: C01111nents: (oil pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 8 ' cl 7 FVON saainlaS 82221JON p88dSjy2 ! 1 lNd8O :q trOQI I dab Page$of 11 OFFICIAL INSPECTION FORM_NOT FOP VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: Au ist 18,2004 TIGHT OR HOLDING TANK: none (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 inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: none .(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Coaunents:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) PUMP CHAMBER: none (locate on site plan) Pumps in working order:(yes or no) Alarms hi working order:(yes or no) Comments(note condition of pump chainber,condition of pumps and appurtenances,etc.): 8 F � 7GfR ' oN saainaa� aaeg�aoW paadS�Vg !l WrIRO �G b007, ' I ' daS Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Faller Road Centerville Owner: Starilpy Smiley Date of Inspection: August 1.8.2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why; Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries,number _leaching trenches, number,length _leaching fields,ntunber,dimensions _overflow cesspool,number —innovative/alternate system Type/name of Technology Comments:(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching nits appeared unsaturated.No evidence of surfacepondintr breakout, lush vegetation,or other evidence of hydraulic failure was observed CESSPOOLS: none (cesspool mast be pumped at time of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer; Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY:none (locate on site plan) Materials of constniction: Dimensions:_ Depth of solids: Conitttents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): .9 nI ' d 7QFR'ON S801AJ8S 82eg�]ON p88dSJu2! 1 N60 : 9 ti00Z ' t A8 S i Page.10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18,2004 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'(Locate where public water supply enters the building) LOCATIONS A B LEACH O Z I 26 f t 20.5 Ft vir seTAiNK 2 23.5 Ft 32 f t 3 28.5ft 41Ft B A EXISTING DWELLING # 63 W J WW < I FULLER ROAD NOT TO SCALE 10 � II ' � 7.GCR ' oN saoinaa� a�eg�aoW paadClu° i � W�F� ;G ti(1f17. ' f ' day ,Page 11,of I 1 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley,Smiley Date of Inspection: Aug st 18,2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 20 feet Please indicatc(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked.date of design plan reviewed T Observed Site(abutting property/obscrvation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators, installers-aaach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Bannstable GIS department records indicate ftlt propem is 20 feet above>;roundwater i<1ble. 11 71 7QPP , ON 22E21JON D@8dg1Q211 INARA : C tH7 ' 1 d8S ECOJECH Environmental 43 Triangle Circle Sandwich, MA 02563 508 364 0894 Judy Notz October 8, 2004 363 Sea Street Re: Leach Pit Evaluation Hyannis, MA 02601 63 Fuller Road Centerville, MA Ms. Notz, On Friday October 6, 2004 I went to 63 Fuller Road and dug up the leach pit serving the dwelling to determine its dimensions and leaching capacity. I found a precast leaching pit 6 feet in diameter and 6 feet in effective depth with 2 feet of stone around it. Applying the pre 1995 design calculations yields a flow capacity of 550 gallons per day which is more than sufficient for a three bedroom dwelling. I also determined that the pit was dry with no evidence of past failure. Please call me at the above number if you have any further questions. QAV . Cc'YJGH,ANOWR 1093 Sinc �Is'T �NI TARP David D. Coughanowr, RS ECOJECH Environmental www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSrENTSco ;� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 63 Fuller Road > Centerville Owner's Name: StanleySmiley iAAP Owner's Address: 142 Perkins Street PARCEL f , co Melrose, MA 02176r-- Date of Inspection: August 18,2004 .OT Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Enviromnental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 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 fimction and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature G.�/� �> Date: Avy6 2DO The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note==> Aseptic systeni is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. 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. ""Thus report only describes conditions at the time of inspection and wider 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 I ct 'A Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18,2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no, or not determined(Y,N,or ND). in the_for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not), is structurally unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The 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 four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 Page 3 of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18. 2004 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 and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health (and public water supplier,if any) determines that the system is functioning in a manner that protects the public health,safety,and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 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 by 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►itrogen and►itrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3) OTHER 3 t Page 4 of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18, 2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this detennination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. , X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is witlun 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is witlun 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(Tlus system passes if the well water analysis, performed by a DEP certified laboratory, for colifor►n bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of aimnoiva nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form) No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310.CMR 15.303,therefore, the system fails.The system owner should contact the Board of Health to detennine what will be necessary to correct the failure. E)Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is witlun 200 feet of a tributary to a surface drinking water supply the system is located in a►itrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone I1 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 mider section E or failed colder section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 „S Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 63 Fuller Road Centerville Owner: Stanley Date of Inspection: Augiist 18,2004 Check if the following have been done: You must indicate either"Yes” or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? Y _ Were all system components,excluding the SAS. located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: N Existing information. For example,Plus at the Board of Health. Y Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) 1310 CMR 15.302(3)(b)] 5 i .t Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 19. 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 0 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n1a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): 1 gpd _ Sump Pump(yes or no): no Last date of occupancy: about 6 months ago COMMERCIAL/IND-USTRIAL: Type of establislunent: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no)_ Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings, if available: Last date of occupancy/use:- OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past.(Real Estate agent) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM: X Septic tank,distributieii bat, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) Iimovative/Attenuate tecluiology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age: about 32 years System is assumed to have been installed in 1972 at time of dwelling's construction Were sewage odors detected when arriving at the site: (yes or no) no 6 r . :t I Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: Augnst 18, 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 3 ft Material of construction: X cast iron _40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting, evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound A blockage was discovered and client.arran eg_d to have sewer line cleared. SEPTIC TANK: Yes (locate on site plan) Depth below grade: 30 inches Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle: 28 in Scum thickness: 2 in Distance from top of scum to top of outlet tee or baffle: 9 in Distance from bottom of scum to bottom of outlet tee or baffle: 13 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations, iiilet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Pumping not required at thus time but maintenance pumping is recommended within and everyyears. Liquid level at outlet invert. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out. GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Continents: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: Aug►►st. 18,2004 TIGHT OR HOLDING TANK: none (Tank must be ptunped at time of uispection)(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):_ Alan level: _ Aaann in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee, condition of alann and float switches, etc.) DISTRIBUTION BOX: none (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alanus in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 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: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August. 18,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located, explain why: Type: X leaching pits,number 1 _leaching chambers,number _leaching galleries, number _leaching trenches, number, length _leaching fields,muuber,dimensions overflow cesspool, number innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) Soils above leaching pits appeared unsaturated. No evidence of surface ponding,breakout, lush vegetation,or other evidence of hydraulic failure was observed. CESSPOOLS: none (cesspool must be pumped at time 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 constriction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: none (locate on site plan) Materials of construction: Dimensions:_ Depth of solids: Conuments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 L� Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanley Smiley Date of Inspection: August 18,2004 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'(Locate where public water supply enters the building) LOCATIONS A B LEACH 0 2 1 26 f t 20.5 f t PIT SEPTIC 2 23.5 f t 32 f t o TANK 3 28.5 f t 41 f t. I B A EXISTING DWELLING # 63 W Z J W H 3 I FULLER ROAD NOT TO . SCALE 10 C ` Page I I of I I OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Fuller Road Centerville Owner: Stanlev Smilev Date of Inspection: August 18,2004 SITE EXAM Slope Surface water Clieck Cellar Shallow wells Estimated Depth to ground water: 20 feet Please indicate(check)all methods used to detennine high ground water elevation: Obtained from system design plans on record-If cliecked. date of design plan reviewed Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators, installers-attach documentation) X Accessed USGS database You mist describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is 20 feet above groundwater table. 11 i �® r e i i li I i 3 { pp+ i t i { I � Q ! Y N � � � c �.