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HomeMy WebLinkAbout0047 GLENEAGLE DRIVE - Health LA LEN EAGLE DR. CENTERVILLE191 135 No. 42101/3 ORA p o ESSELTE 10% 0 0 0 0 .� zo ®r I � - s 7 9 R@ a t � i y ` k _J J � � S �- �►Yae i I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 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. General Information 1 _ on the he tabcomputer, use onlythe tab 1. Inspector: key to move your cursor-do not Brad J. White use the return Name of Inspector key. Company Name 45 Paulette Terrace Company Address tam Plymouth MA 02360 City/Town State Zip Code 508-743-5066 S14358 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address,"and that& information reported below is true, accurate and complete as of the time of the inspection. The,inspecttbn was performed based on my training and experience in the proper function and maintenance of—Yon site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 340 ofM Title 5 (310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails- ~`=' ❑ Needs Further Evaluation by the Local Approving Authority 02/11/2011 Inspector's 5in Date The systeector shall submit a copy of this inspection report to the Approving Authority (Board of Health )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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville- MA 02632 02/11/2011 page. Cdy/Town 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: ""--am- System fully meets pass criteria. 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): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address . Christopher Mcgraw Owner Owner's Name information is Centerville MA 02632 02/11/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is Centerville MA 02632 02/11/2011 required for 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. ❑ 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 Y2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive M Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. City/Town 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: ❑ z 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. ❑ E 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. 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is Centerville MA 02632 02/11/2011 required for every 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) 1Z ❑ 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): Number of bedrooms (actual). 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is Centerville MA 02632 02/11/2011 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? E Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available last 2 ears usage N/A g ( Y 9 (gPd)1� Detail: 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 6 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. City/Town 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: Pumped approx 1 year ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ (40) Shared system (yes or no) (if yes, attach previous inspection records, if any) ElInnovative/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): Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 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 information: --Ow System was installed in 1997 per information on file at board of health Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): —�Depth below grade: 29"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): --' Building sewer is in good condition.No visible breaks or dips in piping, Septic Tank(locate on site plan): " Depth below grade: -----;4911►21feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon precast tank 2" Sludge depth: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °LM 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 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 29" Scum thickness 1 9 I Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17° How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ----� Inlet and outlet tees are in good condition. Liquid level is normal. No evidence of leakage in or out of tank. No evidence of high stain. Outlet has a risor on it to within 6"of grade. Inlet cover is 21" below grade in grass area. 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 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C1M ; 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. City/Town 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? 0 Yes ❑ No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 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. 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box is level with no evidence of solids carryover. No evidence of leakage in or out of the box. Box has one line entering it and two lines exiting it. Box is 39" below grade in grass area. Pump Ghamber(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.) Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive - Property Address Christopher.Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ---� ® leaching galleries number: 2- ---—-- -- - ❑ 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.): —Soil is dry. No signs of hydraulic failure. Vegetation is normal. No visible ponding. Top of galleys are 41" below grade in grass area. Galleys had 1' of liquid in them with no visible high stain on sidewalls. Leaching is 25'x 13.2 area. Cesspools (cesspool must be pumped as partt 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 0 No i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C7M 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. City/Town 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is Centerville MA 02632 02/11/2011 required for every 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 'P11CA J. B i C � L4 Al - 2 Al- i ,ate, L49 , 33 yz) L13 .-_... ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 page. City/Town 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: ----- 12'+ 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- 1997Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: "---immP Previous inspection report performed by David J. Burnie and Sons ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: —"-ft-Bottom of S.A.S. is at no more than 6' below grade. Hole was excavated to a depth of 12'with no indication of groundwater. System is above estimated seasonal high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w. 47 Gleneagle Drive Property Address Christopher Mcgraw Owner Owner's Name information is required for every Centerville MA 02632 02/11/2011 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form. Inspection forms may not be altered in any way.. A. General Information Important: When filling out 1. Property Information: forms on tor,use the compute 47 GLENEAGLE DRIVE only the tab key Property Address to move your CHRISTOPHER McGRAW cursor-do not Owner s Name use the return key. 47 GLENEAGLE DRIVE Owner's Address CENTERVILLE MA 02632' Cityrrown State Zip Code Date of Inspection: 12-8-06 Date 2. Inspector: MICHAEL A. BURNIE Name of Inspector DAVID J. BURNIE &SONS SEPTIC SERVICES Company Name 307 A COMMERCE PARK NO. Company Address SO. CHATHAM MA s 02659,.,., Cityrrown State Zip Code.,.; =_? 508-432-7420 Telephone Number B. Certification _�` •° ' I certify that I have personally inspected the sewage disposal system at this address4 and that--the information reported below is true, accurate and complete as of the time of the insp ction. The inspection was performed based on my training and experience in the proper function and mai tenance of onrsite sewage disposal systems. I am a DEP approved system inspector pursuant to S ction 1'5'340 of Title 5(310 CMmt 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rth�er Evaluation by the Local Approving Authority 12-8-06 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 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. title5_2006_blank.doc.doc-03/2006 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 47 GLENEAGLE DR. Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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, 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: CHRISTOPHER MCGRAW.doc.doc•0312006 Titl ial InspXion Form:Subsurface Sewage Disposal System Page 2 of 16 f ssachusetts Commonwealth of Ma Title 5 Official Inspection Form Not for Voluntary Assessments M y.9 e Subsurface Sewage Disposal System Form B. Certification (cons.) 47 GLENEAGLE DR. Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection B) System Conditionally Passes(cost.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 50 feet of a bordering vegetated wetland or a salt marsh title5_2006_blank.doc.doc-03/2006 Title fficial Inspection Form:Subsurface Sewage Disposal System- 11 Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (coat.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 Cityrrown State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cunt.): 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 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: title5_2006_blank.doc.doc•03/2006 Titl vial Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 �� A Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Sway`' B. Certification (coot.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State ZipCode CHRISTOPHER MCGRAW 12-8-06 Owners Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® 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 of 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. Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. title5 2006 blank.doc.doc•03/2006 Title 5 6al Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 i Commonwealth of Massachusetts Title 5 Official inspection. Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Certification (cont.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection 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 gpde 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. title5 2006_blank.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 CityrFown State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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,ojgodWhe 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 ® El 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)] titles 2006 blank.doc.doc-0312006 le 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): UNKNOWN 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 05-495.89 GPD Water meter readings, if available(last 2 years usage(gpd)): 06-79.45 GPD Sump pump? ❑ Yes ® No Last date of occupancy: DaRRENT 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: Last date of occupancy/use: Date Other(describe): title5 2006 blank.doc.doc•03/2006 Ti Official Inspection Form:Subsurface Sewage Disposal System — — ` Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M D. System Information (cost.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: 1-99,4-99, 1-02 PER BOH Was system pumped as part of the inspection? ® Yes ❑ No 1000 If yes, volume pumped: gallons How was quantity pumped determined? MAINT. Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 6 YRS+ PER PERMIT DATED 5-6-99 Were sewage odors detected when arriving at the site? ❑ Yes ® No titles 2006 blank.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System — — Page 9 of 16 ,�� I L) Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information (cont.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection Building Sewer(locate on site plan): 26" 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.): WE VIEWED THE MAIN LINE WITH THE CAMERA AND IT APPEARED THAT THE LINE HAS SLIGHT MISSALLIGNMENT IN IT. Septic Tank(locate on site plan): 20" Depth below grade: 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 ❑ Yes ❑ No ---- certificate)-------------------------------------- -------------------------1000 GALLONS---------------------- Dimensions: 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? SLUDGE JUDGE CHRISTOPHER MCGRAW.doc.doc•03/2006 it al Inspe Form:Subsurface Sewage Disposal System ( Page 10 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information (cont.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owners Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): titles 2006 blank.doc.doc•03/2006 Wf3#Nal Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts ulag Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ,p D. System Information (cont.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 City/Town State Zip Code CHRISTOPHER MCGRAW 12-8-06 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I L10— A, � ' /�G ( - k3" title5_2006_blank.doc.doc•03/2006 TitjpXrOf 110al Inspection Form:Subsurface Sewage Disposal System- � h Page 15 of 16 . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form D. System Information (cont.) 47 GLENEAGLE DR Property Address CENTERVILLE MA 02632 Cityfrown State Zip Code CHRISTOPHER MCGRAW 12-M6 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells /UN-e-- Estimated depth to ground water: . / ¢ ✓ 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: WE REFERENCED THE GROUND WATER TO LAKE WEQUAQUET WHICH IS AT ELEV. 34 PER DONNA AT THE BOH. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW 252 ZONE D 4-5 LEVEL 47.3 ADJUSTMENT=42" You must describe how you established the high ground water elevation: SEE ATTACHED title5 2006 blank.doc.doc-0312006 5 Official Inspection Form:Subsurface Sewage Disposal System- — — � Page 16 of 16 vc f elf t° U� i I L-'4 No. _ _ a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for 3Di5pogar *pftem Construction Permit Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.S/'7 611--r, 5 14 71e 0rt'1//:: Owner's Name,Address and Tel.No.` Assessor's Map/Parcel if/ Installer's Name,Address,and Tel.No. lj 11-G 5 ff Designer's Name,Address and Tel.No. J03-e,4ti U•t aw,--^O.S Jas ep! U�- �Y'•"t°15 Type of Building: Dwelling No.of Bedrooms ..3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil _Ii1r1a/ Nature of Repairs or Alterations(Answer when applicable) Zh rW1/ 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 Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date100, Application Disapproved for the following reasons Permit No. Date Issued ZIr No. G Fee / THE COMMONWEXETH OF MASSACHUSETTS , Entered in computer: ✓ Yes /J PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migogar *pgtem Congtructton Permit Application for a Permit to Construct(4-- epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot NoAll 61,--4 !4(olt Vr%v1:F Owner's Name,Address and/Tel.No. Assessor's Map/Parcel GrwT r vl//G �lJrhklG(y�'A Q I ' r- Installer's Name,Address,and Tel.No. J177-O 3�'f Designer's N/am�e^,�Ad ress and Tel.No. VO$c,P4 U� UpNNOS J0.5 epLi [/��iE?/''• r�'i S I1 O Type of Building: Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. 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) r 1>��/� 2- SDU 0/,W/ j9rr' lX Ui;T 5' -5 ran.-- Aeoaad 2 „ P1=ti jr,,,.,=r 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 Certifi- cate of Compliance has been issued by this Bo d of ealth. Signed .,e Date S- Application Approved by Dates -46 - 119 Application Disapproved for the following reasons Permit No. Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( 4-� Repaired( )Upgraded( ) Abandoned( )by at 5'Z �_W )Cl04�r' 12p.1vi- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. —2 Y dated S 6 �. Installer AsrOA J,c l?'W "as Designer 10.6 The issuance of this permitAh#not be/� s ed as a guarantee that the systemtw' function as desi�ne"fd�. Date �`T "! Inspector ! / ! No. ( / —Z ----------------- � ---- "r /qr/ /3f Fee `� `� ' •----.'.' 7 THE COMMONWEALTH OF MASSACHUSETTS- PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wigpogal *pgtem Congtruction Permit Permission is hereby granted to Construct(4_+ftepair( )Upgrade( )Abandon( ) System located at 517 G1,i=0 Ftig!/ 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 completed within three years of the date of thi e t. Date: Approved by 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed j Septic Systems Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, sl y 'oe hereby certify that the application for disposal works construction permit signed by me dated S— Y— 9' concerning the property located at e17 60ell D� L� ✓�.,�i/i//meets all of the following criteria: • The failed system is connected to a•residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS 1 and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system t ere is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feett above the maximum adjusted groundwater table elevation. (Adjust the groundwater table rising the Frimptor method when applicable] • If the S.A.S.will be Iocated with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface EIevation(using GIS information) Go B) G.W. Elevation Z+the MAX. High G.W. Adjustment g'6.3 DIFFERENCE BETWEEN A and B SIGNED DATE: ;Sketch proposed plan of system on back]. q:health folder:cert huJIS14 CY ol goo/ 6tiits�'�� TOWN OF BARNSTABLE LOCATION /-/7 l'11,00 SEWAGE # VILLAGE r lmd ra- -1 1111 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. S177-07Y9 SEPTIC TANK CAPACITY �,EACHING FACILITY: (type) 2 -.Soo GAI Oo-4-&r -At� (size) NO.OF BEDROOMS BUILDER OR OWNER L9a,- Al PERMTTDATE: S'-G — I COMPLIANCE DATE: .r—/'/-9� Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 faci 'ty) Feet Furnished by ��� S �h 5 SS �L // �TOWN OF BARNSTABLE LOCATION �/� !�z f-'°�/� SEWAGE # VILLAGE /�rJT'/'1��1111i-` ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. 277 aZ "? 2 ,0LI✓-3t /�- t3�pr' SEPTIC TANK CAPACITY /a�U LEACHING FACILITY: (type) 2-S oa 6,V1 �a (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: S-G - ?9 COMPLIANCE DATE: -/'/"97 Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching faci 'ty) Furnished by /5 •'h � SS I