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HomeMy WebLinkAbout0100 GUILDFORD ROAD - Health I100 Guilford. Road Centerville P A = 172 055 E I No. 42101/3 ORA ESSELTE 10% .. - wa lea- ate 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 4_ ,_ - - _ - -, -. - - _._. m_. - T ,. , . , .». : .: �,�, is ,;, - ... , . 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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 P':OF FOUNDATION ELEV. 10 00 ! }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 Grade over tte lank 96.00 Orode OUTS ;.,rT 4 Ln � _. , a __ : . ,. - S , MST jI r i2« tr , F OUAET , �a Q O -: , S , r .. *� 4 3 HOLE H- TD Z 3 IJmdrMua:CovK t c tr GIST. BOX T SAS- 50 �a d, '[' > aQ of Elav,�S. s-O.m or ; ►-'. 13 Greater : . 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 � nr P A S;,.tl t` d .1 , rn fOtMIdA11 3 3 COIICIRETE,FUU. a ra 'u) m ,.; 083 t0 mcfies , ` ; -r > r� { 31.$5 a > rn ao n o A cs . , . 3 HOLE H 10 DISTRIBUTION BO _ t s r >, 37,25 ,; B'h.oi 3 4 t rn o YS P F1L n S TEM R0 E ,,:, > - ' 'N T.TO SCALE .: ed :tons O c«,wact o, Effective C th c >_ o n �T+6 <o . ., 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 T , 1I Ijj I. I. 0 I 1 o DENOTES .EXIST ING t 1 I X 104.46 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 ;, TALLA D IN S » _ . . S LLE iN TA PLAN VIEW: wAs INS »- w __ YSTEM > TH ES N. M ANNE E E3C)C3RAS NCE TO PLA 3-­ REMOVABLE LovTxts' DA ;. A CCOR { AT _ - r - . - . .. _ _ ..,-. -. � _ - F�R D R SAD .. ..� 1 GU1L.D , ,: - r , .. I, 3 mk+ ,, , w Er : - _. it _ _ m ivlet to outlet . 8` kt 2 min. T KU: _8 ,- , i MA OUITIET C E NTE RVI LL.E - - !��, , -T . _ia•min , • _ - _ • ss r L :r r C Ic } ti ns eetn a uao r S7 • \x P . D Y,r , •� RE_ARE B 4.O'mtn. _ o..uni. ,, r deP th , /� uwb t rrt, er:Title � ;: u er of:' rooms. 2 : ulvalent to 220 Gal.:' Da 330 Ga. a M o N mbetfq Y 1 Y P y , s ': . ,, : RM, - Garba a Grinder., No, ,, <. 9 11T �'. A Y - .t _Tf CAR2 ' - I Mi um Min._Per it e _� Leachin Ca acrt Pro osed, 330',Ga. a n&ri E,: . 9. P Y P. Ia Y ,( ,. • ; ,_ „ .. • - ,. _ . L ..,. _.x, r fifi 1 500 AL tic Tank. Y N SERVICES INC. - .r„ .. -. .i ...:._Y. tic Tank . x MO Gol:/Day 0 , :USE G Sep ca NVIRONbrE TAL sep 0 20 40- 50 4 t , 0« f < ; AR A.-: Ustn ercolatl4n rate o 2 k► arch B-cr SOIL:ASSORPTiON E m /. o. 9P ..��. _. O 7 .8 ailon� 0., B X .627 `: Ar , 0.74 al s _ ft: x._370 s ft". 2 3 h O_ . _Bottom ea, ,. � END SECT 4 N 9 / q 9 F CROSS SECTION >_ c Sidewall Area. 0.74 al. ft. x '78 ft. 58„ oNans I TE 9 ,, s EAST FALMOUTH, MA 025 a. :, Pr vide 331.80 ollons : A 9 9 A R T - � . . TEL FAX 508 5 48 0796 1 0 CAL 2 1 I NG A 0.83- ]O INCHES EFFEC TIVE DE TH S E „ s . ,. 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