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Home My WebLink About0132 GREAT MARSH ROAD - Health 132 GREAT MARSH RD.,CENTERVILLE A=210.090 i tJPC 12543 No. 53LOR HASTINGS, %IN Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =_= w„ 132 Great Marsh ctLL Property Address Carmelia Ferreira Owner Owner's Name information is Centerville Ma. 02632 06/19/2017 required for every page. Cityrrown 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�y A. General Information / 716 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections r� Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 Si3938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority c� �� 016/20/2017 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. City/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: This 4 bedroom home has a H-10 1500 gallon septic tank and a H-10 D-Box feeding a two leaching pits and a overflow cesspool. At the time of the inspection the leaching was dry. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑� N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): __ __ ❑__ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below)_ ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order-to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. . Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 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: ❑ ® 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. ❑__ ®r Any portion of a cesspool or privy is within a Zone 1 of a public well. ----- - ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each'of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large-system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 132 Great Marsh Property Address Carmelia Ferreira Owner Owners Name information is required for every Centerville Ma. 02632 06/19/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? -- - Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w ,••' 132 Great Marsh— Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: - �- --- Number.of current residents:--T--7— -__. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail In 2016 27,000 gallons were used and in 2015 12,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2016 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from,system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 132 Great Marsh __.-- Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 21" ---- Depth below grade:_ — feet--- Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"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: Standard H-10 1500 gallon septic tank Sludge depth: 1" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments w 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required Centerville Ma. 02632 06/19/2017 page. Cityfrown 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 36" Scum thickness 1" 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----- _ - - - 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 would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r I J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 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" 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.): The H-10 D-Box had no visible signs of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 132 Great Marsh - —_ Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ------- - -------leaching trenches--- number; length:---------- - ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): At the time of the inspection the leaching was dry. Cesspools (cesspool must be pumped as-part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 page. Cityrrown 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 iK�j = 61 . = 7Z 3�-�-- 0 D � S t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is Centerville Ma. 02632 06/19/2017 required for every 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: 14 plus feet 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: 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 to 14 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 132 Great Marsh Property Address Carmelia Ferreira Owner Owner's Name information is required for every Centerville Ma. 02632 06/19/2017 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 G r�� n QyTT�� o F 5r i9 S v 147- t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. 9 •4f " ` l Fee N/C THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migpogal *pgtem Congtruction 3permit Application for a Permit to Construct( )Repair( )0 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 132 Great Marsh Rd., Owner's Name,Address and Tel.No. Centerville , MA02632 Tenant Assessor's Map/Parcel Ins let's e, d sand Tel.No. 7 Designer's Name,Address and Tel.No. Wm. '. orinson Septic Service P.O . Box 1089 Ce t r 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 S and. Nature of Repairs or Alterations(Answer when applicable) Repair D-Box and. put on new cover . 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 Boar He Signed ` Date —l Application Approved'by Date Application Disapproved for the following reasons Permit No. Date Issued }`� `� ! Fee N/C No. _ / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication. for M'igaar *pftem Cougtructiou Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. IJ2Great MRr sh R d., Owner's Name,Address and Tel.No. Centerville , MA02632 F Tenant Assessor's Map/Parcel InsErs Name,Ad�s6d[�JeO1No�e pt 1C Service Designer's Name,Address and Tel.No. P.O. Box 1089 Centerville MA D26 2 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 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 Sand. Repair D-Box and. put on new cover. Nature of Repairs or Alterations(Answer when applicable) 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 f HeAll. �} ¢ Signed - Date 4` ^/ Application Approved Date Application-Disapproved for the following reasons In ,tv � Permit No. l ,J" Date Issued �- r THE COMMONWEALTH OF MASSACHUSETTS BAR NSTABLE;'MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( ) Abandoned( )by at 132 Great Marsh, Centerville, MA has been constructed in accordance_ with the provisions of Title 5 and the for Disposal System Construction Permit No. yov "l 7 2 dated ,1? Installer Designer iv The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector -- O �--- -------------------------Fee N--- No. 7 -77 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwi5po5al *p5tem Cougtructioit Permit Permission is hereby pted to Construct( J Repair(�X)Upgrade )Abandon( ) System located at GreatMars .� ,(,entervl le, MA 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 this Kt- Date: - / 1 Approved b DEC 08 198 11:26AH REEF REALTY LTD P.3 Ccmmonweblm of Massachusetts Execuiive Office of Environmental Affairs Department of • Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Map Number R-210 Parcel Number 090 PROPERTY ADDRESS; 132 Great Marsh Rd.Centerville ADDRESS OF OWNER: DATE OF INSPECTION: 11-14-9t3 NAME OF INSPECTOR: William Robinson 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: W. E. Robinson Septic Inspections MAILING ADDRESS: 43 Tomahawk Drive Centerville, MA 026332 TELEPHONE NUMBER: (508)775-7986 CERTIFICATION STATEMENT I certify that l 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 Inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: r DATE: 11-14-98 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,Y applicable and the appWing authority, INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 1 Any failure criteria not evaluated are indicated below. COMMENTS: System Is Tltle-5 and is in good working condition at time of inspection. 8 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 b the Board of Health, will pass, Indicate yes, no, or not determined(Y, N, or NO), Describe basis of determination in all instances. If"not determined', explain why not) The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20) years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial Infiltration or exflltration, or tank is failure is imminent. The system will pa9t;Inspoclign if the existing septic tqnk IP r11111090.4 with a conforming septic tank as approved by the Board of Health. Page 1 08 10 (ro iacd 04/23/97) DEP on the World Wide Web:http:llwww.magnet.state.ma.uNd DEC 08 '98 11:26AM REEF REALTY LTD P.4 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 132 Great Marsh Rd.Centerville Ma. 02632 Owner: McInnis Date of Inspection: 11-14-98 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed 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 the Board of Health). Describe observations: Broken pips(s)are replaced Obstruction is removed Distribution box is leveled or replaced 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condltions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid), 3) OTHER (revised 04/25/97) page 2 of 10 DEC 08 '98 11:26RM REEF REALTY LTD P.5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 132 Great Marsh Rd. Centerville Ma. 02632 T Owner: McInnis Date of Inspection: 11-14-98 D]SYSTEM FAILS: You must indicate either'Yes'or'No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- Loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clo9ged SAS or cesspool. Liquid depth in cesspool is less than 6' below invert or available volume is less than'A.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstruct pipe(s) -- - - Number of times pumped Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater �^ Elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a Surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either Yes'or'No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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-)WPA)or Mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. (revised 04125/97) Page 3 of 10 DEC 08 '98 11SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM P.6 PART B CHECKLIST Property Address: 132 Great Marsh Rd. Centerville Ma. 02632 Owner: McInnis Date of Inspection: 11-14-98 Check if the following have been done: You must Indicate either"Yes" or"No"as to each of the following: Yes No X Pumping Information was provided by the owner, occupant, or Board of Health. X None of the system components have been pumped for at least two weeks and the system has not been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined, Note if they are not available with N/A. _The facility.or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or Industrial waste flow, X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site, X The septic tank manholes were uncovered, opened, and the interior of the septic tank was X Inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid Depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants, if different from owner)were provided with information on the X Proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B4O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 04/2S/97) Page 4 of 10 • DEC 09 '99 11:27AM REEF REALTY LTD P.7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:, 132 Great Marsh Rd,Centerville Ma, 02632 Owner: McInnis Date of Inspection: FLOW CONDITIONS jeSIDENtIAL;_ Design flow: 110 g.p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no) No Water meter readings, if available(last two (2)year usage(gpd): Sump Pump(yes or no): No CO RC INDUS IA • A Type of establishment: Design flow: Gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: NIA System pumped as part of inspection:(yes or no) No If yes, volume pumped: Gallons Reason for pumping TYPE OF SYSTEM X 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) I/A Technology etc, Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information. 5.18-83 Permit#83.188 18 yrs. Sewage odors detected when arriving at the site: (yes or no) No (revised 04/25/97) page 3 of 10 DEC 08 '98 11:27AM REEF REALTY LTD P.8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 132 Great Marsh Rd. Centerville Ma. 02632 owner: McInnis - Date of Inspection: - BUILDING SEWER: (Locate on site plan) Depth below grade: 38" Material of construction X cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (Locate on site plan) Depth below grade-,—-10" Material of construction X concrete metal Fiberglass Polyethylene _ other(explain) If tank is metal, list age is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 111x61X5' 1500 CST Sludge depth: 31' Distance from top of sludge to bottom of outlet tee or baffle. 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 2" How dimensions were determined Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc,) Tank is in good working condition at time of inspection. 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/26/97) page 6 of 10 �. DEC 08 '98 11:28AM REEF REALTY LTD P.9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 132 Great Marsh Rd. Centerville Ma. 02032 Owner; McInnis Date of Inspection: 11-14-98 TIGHT OR HOLDING TANK: none (Tank must be pumped prior to, or at time, of inspection) (Locate on site plan) Depth below grade. Material of construction concrete — metal Fiberglass .— Polyethylene other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: _ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,) D-box Is In good working condition. PUMP CHAMBER; None; (locate on site plan) Pumps in working order. (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/23/97) Page I of 10 DEC 08 '98 11:28AM REEF REALTY LTD P.10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 132 Great Marsh Rd.Centerville Mo. 02632 Owner: McInnis Date of Inspection: 11-14-98 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 2-LP-1000 leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number, - 144'block -— alternative system: - Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,) CESSPOOLS: (locate on site plan) Number and configuration: 1 Depth-top of liquid to Inlet invert: 30" Depth of solids layer: 1° Depth of scum layer: Dimensions of cesspool: Materials of construction: Con block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection) Comments:; (note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.) PRIVY:None; (locate on site plan)none Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) paqA 9 of to DEC 08 '98 11:28AM REEF REALTY LTD P. 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 132 Great Marsh Rd.Centerville Ma. 02632 Owner: McInnis Date of Inspection: 11-14-98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) � �3a Pi:>ae POW b� 5; f: AIM O �l 4'' P� �p�wae WE ShN id VOT SeP fk sys+e� beY��tid (zoviaed 04123/97) Page 9 of 10 DEC 08 '98 11:28AM REEF REALTY LTD P.12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 132 Great Marsh Rd.Centerville Ma. 02632 Owner: McInnis Date of Inspection: 11-14-98 Depth to groundwater 15+ feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine It from local conditions Checkwith local Board of health Check FEMA Maps Check pumping records Check local excavators,installers- X Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) USGS Charts and Data. (revised 04/25/97) Page 10 of 10 W - 111 - THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL -PROTECTION BE IT KNOWN THAT William E. Robinson, . Jr. A Has satisfied the Department's qualifications as required and is hereby CE W authorized to use the title W W CERTIFIED TITLE 5 SYSTEM INSPECTOR ' as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection: m m U wA April10, 1995 Aging Director of the - wn of Water Pollution Control r DEC 08 '98 11:29AM REEF REALTY LTD P.14 Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection IN One winter Street,Boston,Ma. 02108 John GrAd D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F,WELD .,K (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Govemor V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address; 132 GREAT MARSH RD.CENTERVILLE Address of Owner: Date of Inspection: 11127/96 (If different) Name of Inspector: JOHN GRACI 91111 FERREIRA:37 SEA MEADOW CIRCLE CENTERVILLE MA.02632 1 am a DEP approved system Inspector pursuant to Section 15.340 of rifle%(310 CMR 15,000) Company Name,Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes TIW Inaseclorn is based an c0beds deAned M TIW V — Conditionally Passes code al0CMR16509.My findings 3leafhoap+esystemIs performing stove t;Me ofafe inspection.W Inspecbere does Need ther Evaluation By the Local Approving Authority natlmplysnytearantyar0uoranmeaforalanoevbdMe X Fells sepse system and any of Na eampanenis uaaful Ira. Inspector's Signature: , Data: 11128111111 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection,. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority, INSPECTION SUMMARY: Check A, 8, C,or D: A] SYSTEM PASSES: I have not found any Information which indicates that the system violates any-of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If 'not determined', explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Cer tfleate of — Co7hpllance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfltration,or tank failure is imminent.The system will pass inspection•i(the existing septic tank is replaced with a conforming septic tank as approved by the Board of Heelth, Re✓sedo=787) One VYlnter Streat • Boston,Massachusetts 02108 a FAX(617)556-1049 m Telephone(617)292.6500 f DEC 08 198 11:29AM REEF REALTY LTD P. 15 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: 132 GOAT MARSH RD.CENTERVILIX Owner: SID FERRMFtA:37 CEA MEADOW CIRCLE CENTERVILLE MA.02832 Date of Inspection,11f27101 Sewage backup or.breakoutor high static water level obserVed.ln.the distribution hox is due to a brokeo. or obstructed pipe(s)or due to broken,Settled or uneven distribution box The system will pass inspection If (with approval of the Board of Health),Describe observations: broken pipe(s)are replaced obstruction is removed distribution box Is leveled or replaced _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 Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet or 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 HOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT., _ The system has a septic tank and soil absorption system and is within 1 DO feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other Dj SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: x I have determined that the system violates one or more of the following failure criteria as defined 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 in fsclllty or system component due to an 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 cesspool. x_ SAS is in hydraulic failure. lrerlaeaaen1�871 . DEC 08 '98 11:30AM REEF REALTY LTD P.16 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _. PART A -r CERTIFICATION (continued) Property Address; 132eREATMARSMRO.cEfTEAVLL9 Owner: 010 FERREIRA:37 BEA MEADOW CIRCLE CENTERVILLE MA..02632 Date of Inspection:11r27I®a D]SYSTEM FAILS(continued) Yes No _ 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 N0 due to clogged or obstructed pipe(s). — Numbers of times pumped _c Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —x Any portion of a cesspool or privy is within 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 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 —' — acceplable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for eoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen, E] LARGE SYSTEM FAILS: You must indicate either"Yee"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ The'system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No x the system is within 400 feet of a surface drinking water supply z the system is within 200 feet of a tributary to a surface drinking water supply x 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. t (nvlsod 0�litA7) ' DEC 08 198 11:30PM REEF REALTY LTD P.17 SUBSURFACE SEWAGE D18POSAL SYSTEM INSPECTION FORM PART 0 CHECLIST — — Property Address: tax GREAT MARSH RD.CENTERVILLE Owner: SID VERMIPA:37 OVA MEADOW CIRCLE CENTERVILLE MA,02e32 Date of inspection:f127►o8 Check if the following have been done;YOU must indicate either"Yes"or"No"as to each of the following: ,t_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — "— flow rates during that period. Large volumes of water have not been Introducod Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with NIA. x The facility or dwelling was inspected for signs of sewage back-up' T x _ The system does not receive non-sanitary or industrial waste flow. x — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of consiruction,dimensions, depth of liquid,depth of sludge,depth of scum. I The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants,If different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information, Ex.Plan at B.O.H. x Determined in the field(Y any failure criteria related to Part C Is at issue,approximation of distance is -- — unacceptable)(15,302(3)(b)) r (nvleed WRTA7I , e DEC 08 '98 11:30AM REEF REALTY LTD P. 18 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 132 GREAT MARSH RD.CENTERVILLE Owner: amFERREIRA:37REA MEADOW CIRCLE CENTERVILLE MA.o2e32 Date of Inspection;11127198 FLOW CONDITIONS RESIDENTIAL d,/bedroom for S.A.S. Design flow: = g'p' Number of bedrooms: a Number of current residents:o Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye% Seasonal use(yes or no): No last tvVD 2 year usage d Water meter readings,if available;( ( )y 9 (gP ): Sump Pump(yes or no): No �. Last date of occupancy.sYVMMWAS LAST OCCUPIED 6 MOMS AGO 1 u a��E',0re �- COMM RCIAL/INDU�RLAL_ " Type of establishment 'us Design flow:C gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: Ne Last date of occupancy.' OTHER:(Describe) r" Last date of occupancy' GENERAL INFORMATION PUMPING RECORDS and source of Information: nra ' System pumped as part of inspection:(yes or no)N_ If yes,volume pumped: G gallons Reason for pumping: da TYPE OF SYSTEM x Septic tank/dlstribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous Inspection records, if any) I/A Technology etc, Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)apd source Information: 19TB FOR ORJeINAL CEMIPOOL V"NEW BYSTM ADDED W 1883 Sewage odors detected when arriving at the site:(yes or no) No pevUeeoarY1S7) r DEC 08 '98 11:31AM REEF REALTY LTD P.19 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C- --- SYSTEM INFORMATION(continued) Property Address: 132 60AT MARSH Ru.CENTIERVILLS Owner: 01D FERREIRA:31 DEA MEADOW CIRCLE CENTERVILLE MA 02032 Data of Inspection:11127ioa SEPTIC TANK: x (locate on site plan) Depth below grade: 6" Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank Is metal,list age_a—.—. Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L1o,y,H3,rw6'e" Sludge depth:T" Distance from top of sludge to bottom of outlet tee or baffle:2T" Scum thickness:e" Distance from top of scum 10 top of outlet tee or baffle:6" - Distance form bottom of scum to bottom of outlet tee or baffle:15" How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) SE"c TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS, GREASE TRAP: (locate on site plan) Depth below grade; Witlene_other{ P ex lain Material of construction: Polyethylene Y Y ) Dimensions; r Scum thickness:n Distance from top of scum 10 top of outlet lee or bafne:rim Distance from bottom of scum to bottom of outlet tee or baffle:r" Date of last pumping,. comments: (recommendation for pumping, condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural Integrity, evidence of leakage,etc.) Na BUILDING SEINER: (Locate on site plan) Depth below grade: v Material of construction: cast iron_40 PVC_other(explain) Distance tram private water supply well or suction line"WN Diametec,_,_,rve_ pimments:(conditions of joints,venting,evidence of leakage, etc.) (rawleed oarlTlerl DEC 08 198 11:31AM REEF REALTY LTD P.20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 132 GREATMARSM RD.CENTERVILLE Owner: 6113 FERREIR A:37 8EAMEADOW CIRCLE CENTERVILLS MA.02822 Date of Inspectlon:11127192 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Kr+ Material of construction:_concrete_metal_FRP_Polyethylene_,other(explain) Dimensions: ra Capacity: nb gallons Deslgn flow: rra- _ - gallonstday — - Alarm level: m Alarm in working order?_Yes!No Date of previous pumping' Comments: (condition of inlet tee, condition of alarm and float switches,etc.) ry. DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: rh Comments: (note if level and distrlbutlon Is equal, evidence of solids csrryover,evidence of leakage into or out of box etc.) DISTA O ION BOX IS UNSOUND AND NEEDS TO BE REPLACED PUMP CHAMBER: (locate on site.plan) 7 Pumps In working order:(yes or no)Ns Alarms in working order(yes or no)_r v Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc,) �a .s. lnvNeA Oera7�9T) DEC 08 198 11:31RM REEF REALTY LTD P.21 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION (continued) Property Address: 132 GREAT MARSH RD.CENTERVILLE Owner: etc FERREIRA:37 SEA MEADOW CIRCLE CENTERVILLE MA 02832 Date of Inspection.11f77)02 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible,excavation not required,but may be approximated by non-inirusive methods) If not determined to be present,explain, nb Type: leaching pits, numoer: 2•Wo00ALLONSLEACHPrB leaching chambers,number:Ne leaching galleries,number:nh leaching trenches, number,length: nra leaching fields,number,dimensions: overflow cesspool, number:ONEBLOCKMRFLOW Alternate system: rA Name of Technology:_r.& Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PR9 9M0W 31CN8 CF BEINO FULL OVER PIPES,Pr0 ARC PAWTHE EFFECTIVE DEPTH OF LEACHING,THERE WAS STILL V OF WATGR IN TWO OF rHSM THEM AFTM SMO OF UNOCCUPANCI CESSPOOLS: (locate on site plan) Number and configuration: ►a Depth-top of liquid to inlet Invert: r0s Depth of Bonds layer: rft Depth of scum layer: Dimensions of cesspool: n►e Materials of construction: rya Indication of groundwater: rb inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) r>fe PRIVY:_ (locate on site plan) Materials of construction: We Dimensions: Ne Depth of solids: n1a Comments:(note condition of soil,signs of hydraullc failure,level of pending, condition of vegetation, etc,) Rle v, Ue�Uea OarJTl97) DEC 08 '98 11:32AM REEF REALTY LTD P.22 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 132 GREAT MIARBM RD.CENTERVILLE 91D FERREIRA:97 SEA MEADOW CIRCLE CENTERVILLE MIA.02022 11r171s8 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where publlc water supply comes into house) - - -- _. -- - -- becC �A oFj Vp p C ° o AA 3 N� Ae a A b 0 AEA 33c B c yap e o `il 6 F�q. f sE to Nr4rd0eRf197) DEC 08 '98 11:32AM REEF REALTY l_TD P.23 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 132 GREAT MARSH RD.CENTERVILLE 910 FERREIRA;37 SEA MEADOW CIRCLE CENTEAVILLE MA 02632 1127106 , Depth of groundwater Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record, Observation of Site(Abutting property, observation hole, basement sump etc•) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local e)cavators,installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) uscs MAPS AND CHAM t 6-o„4edG&V07) Pap 18 at 10