HomeMy WebLinkAbout0100 GUILDFORD ROAD - Health I100 Guilford. Road
Centerville P
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No. 42101/3 ORA
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name /
information is required for every Centerville V Ma 02632 6-7-18
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
on the computer,..
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
B&B Excavation
WOAQ
Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113747
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
6-7-18
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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurfa Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every Centerville Ma 02632 6-7-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete ail 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:
The system was in working order at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every Centerville Ma 02632 6-7-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑_ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every Centerville Ma 02632 6-7-18
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 %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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.
❑ ® 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-
101000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 1.5.303, 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every Centerville Ma 02632 6-7-18
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?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (Actual) _3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every Centerville Ma 02632 6-7-18
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gP ))�
Detail
2016- 11,000gallons 2017- 13,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
Commercial/industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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: Owner-last pump was in 2015
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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:
2003
Were sewage odors detected when arriving'at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other (explain):
Distance from private water supply well or suction line. Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 9
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: 1000gallons
Sludge depth: 6
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30"
Scum thickness 3
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 13
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.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need
of pumping at this time and should be pumped every two years for maintenance.
Grease Trap (locate on site plan):
Depth below grade: NA
p g feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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: NA
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-31.13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is
required for every
Centerville Ma 02632 6-7-18
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
11
Comments.(note if box is level and distribution to outlets equal, any evidence.of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not
show signs of back up.
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.):
NA
* 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 5 infiltrators
36'x11'x10"
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was Y2
full when viewed.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts '
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4M . 100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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
Back
B
Deck
Al-27` �
A2'3W
B1.49' 0
B2-68'
L
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 100 Guildford Road
Property Address
Stephen & Kathy Booth _
Owner Owner's Name
information is required for every Centerville Ma 02632 6-7-18
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: No GW @ 144"
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: July-25-03
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:
Plan on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Guildford Road
Property Address
Stephen & Kathy Booth
Owner Owners Name
information is required for every Centerville Ma 02632 6-7-18
page. CityTrown 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
,r
Commonwealth of Massachusetts �'Z
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
100 GUILDFORD RD `Tl Property Address =
VELLONE
Owner Owner's Name / 7t
information is required for CENTERVILLE V MA 02632 11-5-15
C'=
every page. Cityrrown State Zip Code Date of Inspection
rrr�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information �� 3� 2
When filling out /
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
508-420-4534 S 14297
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
11-5-15
I nS p etTo-f nature 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.
Sin 113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•P 1 of 17
t s 3 P 9 P Y
I f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every 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:
® 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:
AT TIME OF INSPECTION SYSTEM MET OR EXCEEDED ALL PASSING REQUIREMENTS. THIS
REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR
INCREASED USE.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
- ❑ _ -broken pipe(s) are replaced _ ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 at 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Ij Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every 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.
❑ ® 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
El El Area
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
r '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is CENTERVILLE MA 02632 11-5-15
required for
every page. Cityrrown 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?
® El available
as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 per assessing Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
according to as built card system consists of a 1000 gallon septic tank, d-box and 36x11x10inches
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
system is not designed for a garbage disposal water usage for 2013----233 2014----222 gpd
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 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•3113 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
M , 100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: currently occupied
Date
Other(describe below):
General Information
Pumping Records:
-Source of information: owner stated yearly pumping
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
s.a.s installed in 2003 as per as-built card
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1.5
Depth belowgrade: 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: 1000 gallon
Sludge depth: light
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is CENTERVILLE MA 02632 11-5-15
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness light.
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? wooden pole
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank looked fine at time of inspection. Owner said he has system pumped yearly
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owners Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design-Flow:_ _ ._ ..� . _ . ._ - - -- gallons per day -
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 111 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is CENTERVILLE MA 02632 11-5-15
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
il
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.):
box was opened and showed no signs of failure or surcharge at time of inspection. there appeard to
be three outlets in the d-box indicating that the original pit was still hooked up as well.
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:
there were no measurements or observation ports found on the s.a.s so the inspection was basedon
the d-box.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 100 GUILDFORD RD
Property Address
VELLONE
Owner Owners Name
information is CENTERVILLE MA 02632 11-5-15
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
infiltrators
® leaching chambers number: 36x11x10"
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
there wer no measurements to the s.a.s or observation ports so we were unable to locate the actual
infiltrators.
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•3113 Title 5 Official Inspection Forth: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 100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. Citylrown 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is CENTERVILLE MA 02632 11-5-15
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 5
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. 11 of 2015
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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
100 GUILDFORD RD
Property Address
VELLONE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 11-5-15
every page. Citylrown 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
t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 or 17
e
OWN OF STABLE
LOCATION SEWAGE # 2 t✓i.3 3.5 j
VILLAGE Cep' %' ASSESSOR'S MAP &LOT
INSTALLER'S NAME:&PHONENO.
SEPTIC TANK CAPATY s
LEACHING FACILITY: (type) N� T'Rl Qy�`t(, (size) i3riO�t�! 1.61011
NO. OF BEDROOMS
BUILDER OR OWNE
PERMTTDATE: 7 �� COMPLIANCE DATE: 1 it
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
1 Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
ti Furnished by
D
4
a
r.
r ��
IC f l9�
� �'� ���
�6-
,.
y�,
,38- 6
o
_ No. ZDo3-3 6-1 f FEE Jam/
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �GCn n;cb�e ,MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair><Upgrade( ) Abandon( ) - ❑Complete System ,Individual Components
Location A V^ Gang'JA Owner's Name A f1 Er
Map/Parcel# Address ?_q 5 (,JQ Q
Lot# 3 Telephone#
Installer's Name 5 - C Designer's Name
Address �C 'C�. *. Addressli3c,, SG
Telephone# l�g — 5 \0 Telephone# 5Lk A o l0 26 10
Type of Building \ \Q���2I1Q� Lot Size 15 , 5Z9 bq.ft.
Dwelling-No.of Bedrooms �1f`1(''2� C n Garbage grinder (,b
Other-Type of Building N8(l? \� No.of persons
.,�Showers (1�,Cafeteria (v�
Other Fixtures �Q.V Q"C�y + �\Tt�`Qn vr� 113vC1 Ly`1 �p
Design Flow (min.required) 33o gpd Calculated design flow 3ti Design flow provided 33\ A gpd
Plan: Date \ Number of sheets ` Revision Date ._
Title �COP8�2� .=w�k c SA V c�crck,&t�
Description of Soil(s) 10 c'
Soil Evaluator Form No. Name of Soil Evaluator + )9 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
-":G iING ENGINEER MI MST .
FALLAT!ON AND CERTIFY E"
CYSTi EM WAS INSTAL-LE;a ..:
The under 'fined agrees to install the above described Individual Sewage Disposal System in accociiince;widi"ihe�provisions of TITLE 5 and
further agr s to n t to place em in o ration until a Certificate of om fiance has been issued by the Board of Health.
Signed p Date �� 03
7`3c�D3
Inspections
�•-'t"-^w..,......._+,.^""A'°-.,.,r,/'•�` �.i°"�'"`F"..,,�:. .. 'w.r,.�"!'+-.�. .,.!"'P",=�., �.�"--" °,`�'r..-.,y,,�.,,-w. _'�u�:�..�-. •.'[.:•-:�r-f`'`, .r:,., t�-.�.:{-.. .�-+1, ' -
.�:
E
1 Board of Health, C_C n; G , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair><Upgrade( Abandon( ❑Complete System ,Individual Components,, '
Location (�0 , �C'� � r, �11�e Owner's Name A nne C1S
Map/Parcel# V .
�g f 1 + Address 2-r4 �ac�5-� Wq
s
Lot# I I '� (--, Telephone# ik
Installer's lame � \ utC�/ ' Designer's Name cwnU
Address Address .,.
`1�cCc�noJ c,, 3c�x toad -, � Mbu-� MA_
Telephone# /k� - E6'��� Telephone# ` y -(J ZS�Ia
Type of Building 1O t�2(�'1 �C1t-� Lot Sizey 1 �`� -3Z!q sq.ft.
Dwelling-No.of Bedrooms 1vac-'e-'e L ) _ y Garbage grinder qA
Other-Type of Building No.of persons+Showers (VS,Cafeteria (pl'
�.. Other Fixtures C 1n ���f ,L.ja C�M
Design Flow(min.rre�quired) ��� gpd Calculate design flow �J d Design flow provided ��gpd
Plan: Date T Number of sheets Revision Date
Title
Description of Soils) � C' f .,,r<"� �..�C.(1 v
Soil Evaluator Form No. Name of S oil Evaluator l_CdYl{1 J-) Date of Evaluation.,
y
DEE GRIPTION OF REPAIRS OR ALTERATIONS �i' # A0 -Z)`G C1.
The undersigned agre>Moto install the above described Individual'Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es ton t to place the em m o eration until a Certificate,.of om liance has been issued by the Board of Health.
Signed � Date J 3- 6 -3
n �S'
Inspections _
No.7 0O 3— 35'
COMMONWEALTH Of �'ASSACHUS¶ TTS FEE
Board of Health, " p MA.
CERTIFICATE OF COMPLIANCE
Description of Work:YIndividual Component(s) ❑Complete System ��,J
The unde signed.=he eby certify that the Sewage Disposal System; Constructed ( ),Repaired (�`,Upgraded ( ),Abandoned ( )
at
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applica 403-351 dated '71 3e G3 . Approveq sign"i Flow- (gpd) j
Installer
Designer: Inspector: Date,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 2ov 3- 35 / FEE S
C®MMONWEA11100F MASSACHUSETTS
Board of Health3g m�(/(.�CJ"_. MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hhereby granted to;
to; gnstruct /) R�ep/air( Upgrade(� �)/ Ab ndon( ) an individual sewage disposal system
at )O (�C>' .-U�i(il n ,(� U I/ ® as described in the application for
Disposal System Construction Permit No. ���'?5'� ,dated C 3 .
Provided: Construction shall be completed within three years of the date of this p 11 cal dt ns��ust be met.
9r;
.:.Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date '���� Board of Health
L6T l ��
OWN OF STABLE
LOCATION r /� G1"le- SEWAGE # 5
VILLAGE ���' ` ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 45�- STv�g
LEACHING FACILITY: (type) .( �rJ Twyox(size) 3�O'N /K I QII
-,-NO.OF BEDROOMS
BUILDER OR OWNE Vim.
PERMTTDATE: 3e COMPLIANCE DATE: '7 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
P
lT 27 C
Q �1
a P ��
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE Af7 ASSESSOR'S MAP LOT qa
NAME & PHONE NO. A & B CANCO 775-6264
-SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
/,v,®£crl !o
DATE 901INS III= o�
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
I�
36'
e 3 �- 6 #.
o
d
a
Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 N • u�
sru.o�
!NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only,
PERCOLATION TEST AND SOIL EVALUATION EXENIPTION
FORM
(._ q 444Y hereby certify that the engineered plan signed by me
ac;ec D� concerning the property located at
` 11[A 1 •i �el� C��`�C meets all of the
(ct ow,ng cntehzi:
• This failed system is connected to a residential dwelling only. There ure no
_orimerzia! cr business uses associated with the dwelling.
T? e soil is ciass;,,.ed as CLASS I and the percolation rave is less than or equal to
-ri.nu(es Per inch. The applicant may use historical data to conclude th)s fac, or may
:oncuct Pre!tmj;.ary tests at the site without a health agent present
• There :s no increase in flow and/or change. in use proposed
• There are no variances requested or needed.
The bottom of the proposed leaching 'Lacility will not be located less than fourteen
14 'ee; aonve the maximum adjusted groundwater table elevation. (Adiusc the
nund-wwer cable using the Frimp(or method when applicable)
Please complete the following:
�. rip of Ground Surface E'eyanon (using GIS information)
g; G.VY, Elevation, 35 _ ad,ustment for .nigh G.W..�_'.a...
> =F�Et�CF BETWEEN and BUJ
S'G. tED DATE: �
:3asec ,,ran above r.for-macion, a rcpzilr perl?ut wil! be issued for -)edr^ems
;dd�wt )nal bedrooms are authorized to the future without en,tneerec
.ep:.c system plans.
1ic:11n!r,:W pvccxm9
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: COL-1 16 Cen t\`R Lot No. 1 �
Owner: �ry2_ t; 5 Address: U� ® A
Contractor: �Sy-,,a O\C"-KY AwWdress:
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. .............................................................................. .Date r tCi 03 3J
month/day/year
STEP 2 Using Water-Level.Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well.................................................... �252
OB Water-level range zone ..................................................... C
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... (_Q
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water l"evel for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ..............................................:........................................... I' Z
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ................................................ ��•�
h
Figure 13.--Reproducible computation form.
15
I
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536
July 31, 2003
RE: Certification of Title V Septic System Installation:
Residential Property 100 Guildford Road, Centerville, MA
Dear Sir or Madam:
On July 29, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 100
Guildford Road, Centerville, MA, based on a design drawn by Shay Environmental Services on July 26,
2003.
XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the undersigned at(508)-548-0796.
Sincerely,
CARMEN E. SHA Y
ENVIRONMENTAL SERVICES,INC.
N OF MgSS .
� 9
RMEN oyGN
E.
SHAY
C en ha , R. ., C. No. 1181
a
President a/S T ERA
SgNITAR�P�
rl
OWN OF '� -351
STABLE -
LOCATION s l Cd'� SEWAGE.#
VILLAGE
�Qvi. r ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONfit.
SEPTIC TANK CAPACITY S��`
� LEACHING FACILITY: (type)
S'R1 �R�'l'G (size) / t r Ic t OII
NO.OF BEDROOMS
BUILDER OR O7r-
PERMTTDATE: COMPLIANCE DATE: �1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Feet
jl 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 facility)
Furnished by
{ r
COMMONWEALTH OF MASSACHUSETTS
x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
A 350 MAW STREET
WEST YARMOUTH,MA
m 508-775-2800
Ir
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner's Name: GINNY ENDERS
Owner's Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632 RECEIVED
Date of Inspection JANUARY 26,2001
Name of Inspector:(please print) JAMES D.SEARS �E� 0 2001
Company Name: A&B Canco
Mailing Address: 350 Main Street TOWN OF BARNSTABLE
West Yarmouth;MA 02673 HEALTH DEPT.
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
X Passes
- - Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 1-29-01
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,tie inspector and the system owner shall submit the report to the
appropriate regional office of the.DEP. The original should be sent to the system owner and copies sent tot
he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use..
Title 5 Inspection Form 6/15/2000
/• ttt///
r
t
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY.
Date of Inspection: JANUARY 26,2001
Inspection Summary: Check AM,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
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:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Healthy'
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 100 GUILFORD ROAD
CENTERVU,LE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26,2001
C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
- — --- and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided ---
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
,
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pit is less than 6"below invert or available volume is less than''Xz day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a•cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone H of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26,2001
Check if the following have been done. You must indicate"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 Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
_----�_-- Yes---_ _No
X Existing information. For example,a plan at the Board of Health.
X 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(3xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 5
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 48,000/2000 3,000
Sump pump(yes or no) NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AROUND 1970
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GWNY
Date of Inspection: JANUARY 26,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade: -
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 18"
Material of construction: X concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 11"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,TANK AND COVER 18"BELOW GRADE.OUTLET BAFFLE,OUTLET
SMALL INSPECTION COVER.
GREASE TRAP(located on site plan) N/A
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
1 1
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26 2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: '
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)-.---
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GR-NY
Date of Inspection: JANUARY 26,2001.
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,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.)
ONE(1)1 000 GALLON PRE CAST.PIT AND COVER 28"BELOW GRADE. F WATER IN PIT.HIGH STAIN
LINE AT 2',NO SIGN OF OVERLOADING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUAIZY 26,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benclmnarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
l w All
\fig(
. o
. ya,
g =G
0
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 100 GUILFORD ROAD
CENTERVILLE,MA 02632
Owner: ENDERS,GINNY
Date of Inspection: JANUARY 26,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 48 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA:
WELL SDW 252 AT 48'
ZONED AT 5.3'
ADJUSTED AT 42.7'
Title 5 Inspection Form 6/15/2000 11
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,, *NOTE. ALL='.PIPES :ARE.TO BE SC 'PR XL r
CONt�tE7E COVER
faR LEM3T '
r Foundationo-u to tic twrk
jI
SET U1Q AT Z I h
Ex strn 1 h se :
- 0. Asaumed
bank covers must
_.. ., 3 of 1 8 1/Washed Peoston
�, a
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! }inlshed " _ 3 5 OUTLET 4 wNirin 6 h. d grade 3 , to t t 2 tNashed du7hed Stop a
i sAS fie 00
,
_ avR Q-Boz .96.00 over ., _ - ! Ia�Ogc
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GIST. BOX T SAS- 50 �a d, '['
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s-O.m or ;
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iS5 ,
T.PIPE S-'0.01 foot • 4 SCH, 40 T I
EX1S c� Pw x,
>Z i� 28 ,..: . ._ . Eflocw.0+plh :. x.fRON EXIST.fWiDATM W n O0m , TI N _II�, s tk : a �zs �tr L N` ECTION CROSS SEC 0 9 cIII
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rn
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cs
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,; B'h.oi 3 4 t rn o
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ed :tons O c«,wact o, Effective C th
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.
., LOCUS MAP
N t of o.Scab : _
,`
n SDIL ABSCiRPT''I : SYSTEM S
> _ :o
2.
0
_A NO E
..,- A N )/ GORGE l7 BRIEN GENER L ,.
. > to, INFILTATROR HIGH CRPACITY CH iD LI] DIG E .
6 in,ot,3 4-t t Y --. o
Led` top
E ffectrve Mlafth
Not o-Sco1e t i le:,for Di' safe natificat,on
OR EQUNALENT ,- 1. Contractor rs res s`b g
_: r es.it r d
Bottom o,Test Hare T T3ev. a6.D0 m n r t8 tIOTi of olt_under aund Ut 1#eS';OO
t TIVE ItExIT Is to a d .P A 9r P P
• NOTE: OVERALL HEIGHT'OF INFILTRATOR IS 8 C
No t asrdvrater Obearved"O 144
____ _ .: c tank on dr u on box :boll be` set
2. The set "
a
4 e ,
ieve! on fi of 3/4 i t2 :ton .
r v h `na
3, Backfill should be clean sand or g a el wit
I . :.
stones over 3 :In s¢e.
_ 1'hrs stem rs sub ect #o ins ection during.`installation
.' .
4 SY _ 1 P. ,
b :Carmen E ;Sh -:Environmental Services, Inc.
Y aY
i ccor nce
5. The contractor shall Install this system n a da
15
Y
L T. 3 0
. # roved lane..
setts st'te code the a
LOT #154 15,z with. Title V of _the Mossochu a PP P
T aN � sT
LOT #
,,
�E�cQLA � E
': ,and Local Reguta#cons. -
r ne unters an
, fi. if dun >rnstoilatron the controcto e o
N 39d 19 00 E ►►9 Y
Dote of Percolation Test. DULY 19, 2003
,
-:sort conditions or site conditions that are different
ARMS E. SHAY:R,S. C.S.E.
Test Performed B , C N 100.00 r:desr n
Y' #ram those shown on the sod log ,or rn .au g
rnst le . .H.WAI er Ba ob O ,
ResulEs Witnessed By. _ VER t p B ) m di a rTotrficotion be
instatlafion' must. halt do im a of
R M SERVt NC.
SHAY ENVI ON ENTAL CESti _ ,
4 ode to`Carmen`E_;Sha Environmental `Services, Inc.
- „ 1 m Y
P
1 lion Rate. ess Than 2 M t 32
Perco a L
r he
7. No vehicle or hea machine shall drive ove t
: . vY rY
7.25
2 ,
r ;.unless noted bs"N-20:se tic cam anent:.
sept c system P, P
. , .
ends.
f t s baffiles r e uals on all outlet tee- .- r : r _ tt 8. Instal Tu Tie o q
to._ -v a :
tc3
..,.
_, -3 •, 40 ;NSF,PVC r es.
Test Hole , � 9. i Distnbution:Ernes shall be ;4 diameter Schedule N
�}
AI P P
Shed N ,.'
No. 1 r
4. . : n all 4 diameter 1 4 h 0. All solid ,"tees:'& f Ittr s $h be
_ '
oEP1H sons t1Ev
5chedWe'40 NSF PVC r es with water tight points. ,
PP 9
>98.00 o in
�l M nrci I 'Water-,is Connected to .ALL-OF The Residence and Abutt
11, u pa 9
Loom y
i i h 1 e t.Pro err es Wit in 50_F e
Sand L1t TEST HOLE' 1 P
h _ . :
i s
ELEV 98
.00 0YR3 '.
/ w
THE' PROP RTY;LINE ARE,APPROXIMATE AND
,` i I=aded E S ,
«� A 7.25
0 9
8
d Leach "Pit
_- . :. ' COMPILED :FROM THE SURVEY PLAN GE NERATED BY
San
1N INC. , N BEDFORD MA
r KENNETH R. �'ERREIRA ENGINEER. G, OF EW
oom „ _
L
I
F ROAD F 1 0 'l ORD
..__ TIT C IFI D T PLAN O 0 GU LD
- ---- --- ---------_-� ___,..�_�_.�.. ___ EN LED ERT E P p
TOYRS
/�
98 98 N
CENTERVILLE MA >DATED =DECEMBER 10 2001
9
95.33 V P T P a 32 _, . AND" lS NOT,INTENDED TO SE 'A SUR EY LO LAN.,
, ium bled IT HOULD B ,_,USED FOR O PURPOSE'OTHER THAN-
sand
5 E N ,
O
THE: C' SYSTEM INSTALLATION
SEPTI ,
ZS Y 7/0
EXIST. 1000 i.
}
_, t7a
00
- ,: � ! Se Tank ,
brio ,
. P UT;'AND .
, 1 ING `'LEACH PIT TO >BE P , "ED 0
EX ST
174 , . ,
_ LOT ,.
# LOT 172 -
# ::
FlLLED IN pu�CE.
r ,.. ri; „
, ,, ,., . . . :,.,' K r s:
_ .� _ _ - - --- -- _. . t 1 ONTAf .NG . HATE
,:._ .:<- __ ._�• -_ __...______ >..� ,.__ � __ _ ,_ _,_ _ _� _ __._----_-_-- , __- �_ _'.r __. :_. �_ ._ _ _ _ _. �i4TE.- ANY TR PF'ED.OUT-SO L -C 1 LEAC
S
TIN H PIT BE" D
FROM THE EXIS G LEAC t?tSPO$E
A P ARD OF H T PECIFICATIONS.
N H RK OF S ER BO EAL H 5
3. :;
PROJECT BE MA MA
w-:. r .. r
N ATI OP OF, FOU D ON NO .WETLANDS ARE PRESENT `WITHIN :200 OF%THE PROPERTY
%ISTINO
. E me
;
ELEV. 100,00 Assu d
8 EDROOM' `
Pere 1 GARAGE _ B
LEGEND
c• 40 to 58
D th to Per .
sP -
OUSE •'
a ss Than 2-MPI
_1Y
Perc Rate Le
, I
No served 'ESHWT
;IE
W of Observed �144 Y ,
,_ No`Ground at DENOTES PROPOSED ,
w Ilk
104X1
SPOT GI
<:, : a
1 ,
t I IIIjI
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1I
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0
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o I o PO .,GRADE
I I S T
1 1 .
, :..
t I >
i PL
tt I l 0 �' PROPERTY LINE
I , 1 c
1 i -d
.
o I _ LOT 173 T 0 96 PROPOSED CONTOUR
1 } m ko ASPHALT
1 J
: ,:,'; +n: 5 254 sure Fe t
...., I '`DRN EWAY 1 4 / NT R
,, rn 97 EXISTING ,;CO OU
I I -
I I
�_____ ___ r -___ _ _ . T , 4 �� _�__ _- ------ __ _____ _._
08 + �r, `- 98
t I
-_ DEEP TEST HOLE &
_1 AAr A SS MANHOLES •
t
21 a ocE PERCOLATION TEST LOCATION
t t
-
97 - - -97
-
,I I .I
__�•� _,_-_;,., ti FOOT STOCKADE F N
a t I f 00,00 '� `--`--'
(�' '`
.t o „
_ S 3 d 19 00 W
I. 9
. ' \ {
A SS GONERS FOR THE SEP11G TANK 1
X COMPONENT , 96 - 96
INLET DISTRIBUTION 80 AND lFJd31»IG .1 1
• SET DEEPER THAN.8-INCHES BELOW FINISHED
, / �j � -
ADE SHALL BE RAISED To VATHIN 6 OF
a ,
GR flNISilED ADE
PLA I~ rrLz� , o z aA L_ T
°.' F-11 AS B S OR EQUALS
� '
INSTALL TU TE G WLE
::. a -T•"sue
- -e. ,_ �- -..- .- ..: VISE
. ., �. .. y ER
_,._ USTs SE SEPTIC SYSTEM UPGRADE_
40 FOOT RIGHT `oF WAY EER M P R 0 P 0 D
( NGIN G
ING E WRITIN
1GN IN
PRECAST CONCRETE DES TIFY
sTEEt trNFoRcEn D CER
_ N P PARED FOR
TION A TRICT- RE
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PLAN VIEW: wAs
INS
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TH
ES
N. M ANNE E E3C)C3RAS
NCE
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- .r„ .. -. .i ...:._Y. tic Tank . x MO Gol:/Day 0 , :USE G Sep ca NVIRONbrE TAL
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