HomeMy WebLinkAbout0163 GUILDFORD ROAD - Health 163 Guildford Road
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Centerville
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is required for every Centerville MA 02632 9/24/13
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Importaint Men A. General Information
filling out forms
on'the computer,
use onlythe tab 1. Inspector.
key to move your ��
cursor-do not Jason Burnie tttTTT111 U
use the return Name of Inspector
key.
Neighborhood Waste Water
Company Name
' 350 Main St
Company Address
W.Yarmouth MA 02673
. . .... Cityrrown State Tip Code
508-775-2820 r . S15011
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 19.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
9/24/13
Inspector's Sign Date
The system inspector shall submit a copy of this inspection report to the Approving'Authority(Board a
of Health or DEP)within 30 days of-completing this inspection. If the system is a stared system�r
has a design flow of 10,000 gpd or greater,the inspector and the system owner stiallrsubmit thb-) ,
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 6 use
at that time.This inspection does not address how the system will perform in the future iinderm
the same or different conditions of use. -
t5ns•3113 Title 5 Official lrq)ection Fa subsurface Sewage Disposal System•Page 1 at 17
V
Commonwealth of Massachusetts
Title 5 o#fiiciaY Inspectionform
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner owners Name
infomiation.is Centerville MA 02632 9/24/13
required for every State Zip Code Date of Inspection
page. Cityrrown
B. Certifica-ion (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a conditional pass.This is due to the lines going to the SAS needing to be replaced.
There is no distribution box on this system.The line going from the septic tank to the 1 st leach pit is
orangeburg and crushed.The line going from theist pit to the 2nd pit has a sag that runs the length of
the pipe Also there are no covers that are within 6"of grade.
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):
The system is a conditional pass.This is due to the lines going to the SAS needing to be replaced.
There is no distribution box on this system.The line going from the septic tank to the 1 st leach pit is
orangeburg and crushed.The line going from the 1 st pit to the 2nd pit has a sag that runs the length
of the pipe Also there are no covers that are within 6'of grade.
t5ins•3113 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
1.63 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Canners Name
information is required for every Centerville MA 02632 9/24/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cost.):
® Observation of sewage backup or break out or high static water level in the distribution box-due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
® broken pipe(s)are replaced ® 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 is a conditional pass.This is due to the lines going to the SAS needing to be replaced.
There is no distribution box on this system.The line going from the septic tank to the 1st leach pit is
orangeburg and crushed.The line going from the 1st pit to the 2nd pit has a sag that runs the length
of the pipe Also there are no covers that are within 6"of grade.
❑ 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
TMAD 5 Offidal Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvin on Way Peachtree City, GA 30269
Owner Owner's Name
.information is Centerville MA 02632 9/24/13
required for every State Zip Code Date of Inspection
page cityrrown
B. Cerfifi'cation (cons.)
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
El ® 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
Title 5 Official Inspection Fonrx Subsurface Sewage Disposal System•Page 4 of 17
t5ins•3/13
Commonwealth of Massachusetts
Title 5 official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owners Name
informationrwe."required
is ired for every Centerville MA 02632 9/24/13
page. Cityrrown 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.
❑ (D 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 .
❑ ❑ 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.
t5im•3113
Title 5 Oftidal Inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
----- p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
%'- 163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City GA 30269
Owner Owner's Name
information is MA 02632 9/24/13
required for every Centerville
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?
® ❑ Y
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, open( a, and the interior of the tank
inspected for the condition of the baffle! or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® El information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 795 gpd
l5ins-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 Forth-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is Centerville MA 02632 9124/13
required for enterve
every State Zip Code Date of Inspection
page. Cityrrown
D. System Information
Description:
The system consists of a tank to a leach pit to another leach pit.There is no distribution box on this
system.
Seasonal
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
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Seasonal
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:
t5irs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvin on Way Peachtree City, GA 30269
Owner Owner's Name 02632 9/24/13
information is MA Centerville
required for every state Zip Code Date of Inspection
page Cityrrown
D. System Information (cont.)
--------------
Last date of occupancy/use: Date
Other(describe below):
General Information
pumping Records:
System pumped as part of inspection.
Source of information:
Was system pumped as part of the inspection?
® Yes ❑ No
1000 al
If yes,volume pumped: gallons
How was quantity pumped determined?
si ht glass on truck
maintenance
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
Single cesspool
❑ Overflow cesspool
❑ Privy w
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation
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):
Title 5 Official Inspection Form subsurface Sewage Disposal System'Page a of 17
t5ins-3113
Commonwealth of Massachusetts
Title Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a` 1.63 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is required for every Centerville MA 02632 9/24/13
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:
Septic tank and 1 s<leach pit-unknown Overflow leach pit- 1992
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ®other(explain):
Sch 80 gray PVC
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
We ran a sewer camera up the line and it was ok at the time of inspection.
Septic Tank(locate on site plan):
- -- - - - - Inlet-1'4"Outlet-1'4"
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000ga1
0
Sludge depth:
t5ins,3113 Title 5 Official Inspection Forrtr 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
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Gets Name
information is Centerville MA 02632 9/24/13
required for every State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
0
0
Scum thickness
Distance from top of scum to top of outlet tee or baffle
0
Distance from bottom of scum to bottom of outlet tee or baffle
0
0
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was pumped as part of the inspection. It was at a normal level upon inspection. Customer
requested the pumping for maintenance Both baffles were in place.
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
TiBe 5 Offidd Inspection Form:SWbsurfaoe Sewage Deposal System•Page 10 of 17
Commonwea[fh of Massachusetts
'title 5 Offidar Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City GA 30269
Owner Owner's Name
information is Centerville MA 02632 9/24/13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
t5ins-3H 3 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 11 of 17
Comrnonweaith of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci. 210 Kelvington Way Peachtree City, GA 30269 _
Owner Owner's Name
information is required for every Centerville MA 02632 9/24/13
page. c4rrown 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
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.):
*****THERE IS NO BOX ON THIS SYSTEM*****
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:
SAS was located.
t5ins•3113 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
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is required for every Centerville MA 02632 9/24/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2-6x6 with stone
❑ 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.):
Both pits that make up the SAS,were found to be dry.The inlet line for the 1 st pit is orangeburg,
crushed and needs to be replaced.The inlet line for the overflow pit is PVC but has a sag for the
entire line.
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 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is Centerville MA 02632 9/24/13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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•W13 Tide 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is Centerville MA 02632 9/24/13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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t5ins•3113 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System-Page 15 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary
Assessments
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owners Name
information is required for every Centerville MA 02632 9/24/13
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. feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
SDW-252 Zone D water level 46.3 1 x12= Vadjustment
You must describe how you established the high ground water elevation:
We referenced USGS Topo Maps dated 1974 that shows the property worked on at Elev 60. It shows
Wequaquet Lake is at Elev 34.This gives you a proven seperation in elevations of 26'. From grade to
bottom of the SAS you have a total depth of 8'9"from grade.This gives you a proven seperation of
17'from the bottom of the SAS to where groundwater is known to be.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3M 3 Tide 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
163 Guildford Rd
Property Address
Joe Verocci 210 Kelvington Way Peachtree City, GA 30269
Owner Owner's Name
information is required for every Centerville MA 02632 9/24/13
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
0 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. 200 —�7 7 Fee CJ
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Misposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair(0 Upgrade( ) Abandon( ) ❑Complete System Vndividual Components
Location Address or Lot No. 163 Gv:I X'W TRH Owner's Name,Address,and Tel.No.vv� ve rocc �-
Assessor's Map/Parcel - o Ge,*yvdle a10 Klv*n�bly VJA1l `6,cks ape C'-Y,GA 3 a6 9
Installer's Name,Address,and Tel.No. Me if jar�c,r�UO� � Designer's Name,Address,and Tel.No.
W4� ,, wd Fe f 3S v Nan S3 V/y+
Type of Building: SUS(` 95-dya0
Dwelling No.of Bedrooms �� I�Lot Size sq.ft. Garbage Grinder( )
Other Type of Building / No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided All 4t gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. _
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ZnS 1g// N-/U L>3- 3 Ag&Ue iu 4h,
G
3rAJe, gum mw LInLS 'to C- 6, Lec-d, P;t, —Ly,5J R130ZS ,n A! (P.Mpone4j
�S�l r�h•n 6
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the it ental Code and no o place the system in operatic i until a Certificate of
Compliance has been issued by this Board o th.
Si Date 9 ,9`� 3
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 2017 .37 -7 Date Issued �.?
S
No. —2 J-7 7 Fee U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS es
ftplication for VeipoSal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ). ❑Complete System Z7ndividual Components
Location Address or Lot No. Owner's Name Address,and Tel.No. i
A3 Cjv,'IS'Forcl R) .Jvc Ve rUCc
Assessor's Map/Parcel (, 1)Crv; �� Qjo Klv;on'f e*l A V TCc,ck( rve C� , GA 3 a6 9
Installer's Name,Address,and Tel.No. /Vt f Ir�C,!hUo 21 ` Designer's Name,Address,and Tel.No.
wesF� w4 fe' 35 o M6.,n !-4
Type of Building: SCv" 95-a�jaU
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures / , n
Design Flow(min.required) JAI gpd Design flow provided JL J/' gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. -
Description of Soil
Nature of Repairs orAlterations(Answer whrhen applicable) �nS 1�N �/�� /�/U /�/3- w� ,�ue� y� Jam,.-I-h.n
/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the virD ental Code and no o place the system in operation until a Certificate,of.
Compliance has been issued by this Board o ealth.
Si / Date 9 a
Application Approved by Date -7 7
Application Disapproved by Date
for the following reasons
Permit No. d 17 7 Date Issued qp!714�
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired( Upgraded( )
Abandoned( )by 'Ale j on � �7 �, GtJ�1S�e 4J,o-1c9-.
at Jh �y)�r,��W/% K 1� Ce4 w)11-e has been constructed in accordance l
with the provisions of Title 5 and the for Disposal System Construction Permit No.2 011 37 7dated -_7/2 7/l
Installer / Designer
#bedrooms Approved design flow Aj l� / n gpd
The issuance of th•s permit shall not be construed as a guarantee that the system will notion as designed(
J � v
Date Inspector i
No. _2 013 -� / Fee
i THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem CConstrUction Vermit
Permission is hereby granted to Construct( ) nRepair( Upgrade( ) Abandon( )
System located at IK 3w /) as'Jk,"v AP
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date ) 7/ Approved by ��
TOWN OF BARNSTABLE
LOCATION AP3 6 ullcl-ra"4 A?.A,4 SEWAGE#ff 3
VII L-AGE �L ZZV l IIt' ASSESSOR'S MAP&LOT We
INSTALLER'S NAME&PHONE NO._N 4 C J,6CV k 0-D d(( VC Water`
SEPTIC TANK CAPACITY �X�s'�Ny 16U0 j al
0
LEACHING FACILITY:(type) EXvSTt (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE: /Q
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�/l03
Alt 3e
39Ay
0
I,,�,.
Olo i 1
63,
�,' p
I
FE$..�� .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH APPROVE®
TOWN OF BARNSTABLE ®a►nstable Conserves
Appliration for Disposal Works Touti ur t �` - - 9
give—
Application is hereby made for a Permit to Construct ( ) or Repair n Individual Sewage Disposal
System at
.............�.�a _.....L�. v .... ---------- ---------------- -e. ............................................................
c Location-Address or Lot No.
--- C.�S1................J�.51-AO.J- _1-----------------•---------- --........---------------.�...b .---.-.....------------•----------.-----------
Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms. ...................... .....Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures -
-------------- -----------------------------------------------------------------------------------------------------------•--------------......
W Design Flow......"�'�........................gallons per person per day. Total daily flow..._- .0......................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length----------.......... Total leaching area....................sq. ft.
Seepage Pit No...../------------- Diameter./_......... Depth below inlet...6............ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_----______-__---____.
44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
P4 •-----------------------------------------------•--------------....---------.............--•-.--•--•.........................................................
0 Description of Soil............................................................................... -------------------------------------------••------•-.................................
W
U -----------------------------------•--------------........---------•---------------------------------------------------------•----------•------•--------------------------...........----•-•-----------.
W
x ---------------------------------------------------------------------------------------•----------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.____- _ .............&.�- ...-_.._ j.J.............
a � ?cc 5 7` `S? r,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been isgued by the Ward of alth.
Signed .............. ...... . ........ ........................... .. --- ---------- ...... `.
Dace
Application Approved By . . ----- ...............
.---v...... ... .. .. ....... ....-..... .
Dace
Application Disapproved for the following reason ' .................................. ....... . . ...............................................................................
---------------- ------------ --- -- --.- --- --- .- .....................................................................................- - -.
Permit No. ........ .................... ........................
.... Issued ................ice-----
Dare----------.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
,� lut�a firt� uttl laxk C� rrtu it .�
Application is hereby made for a Permit to Construct or Repair an Individual
PP Y ( ) p (� Sewage Disposal
System at* t �h
.............J".:�. ...... v.��[? G ......'"••-•--:........... ................../-;!!� _r.............................................................
Location-Address or Lot ..o.
Owner
a dress
..............'• L l G``/, S p ( X:�.. `...!_!�_v .�1 `T
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms...... .................................Expansion Attic ( ) Garbage Grinder ( )
a ......
Other—Type of Building .._ ................... No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures =
i Design Flow.......`.5-'<........................gallons per person per day. Total daily flow_-__...... Via.__....._.......__.
W P P P Y Y -•--- .._gallons.
WSeptic Tank—Liquid*capacity......._....gallons Length................ Width................ Diameter--------------_- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------ Diameter./_0-------- Depth below inlet....60........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 a --••-•-•----•••••-----------••............•-•-•..............................................................................................................
Description of Soil........................................................................................................................................................................
x
V ...............--------•••--••••-----•----••---------•••••--------••-•---•--•------•--•••...-------•-•----•-----•-••••--•-----•----•••------••-•-•----••••••----••••--••--•----••------••-•-----•---•--
W
x ..........................-............-----•-•-----------------•---•-•---------•-••-----• ......-----•---•••......-• -•--------------• -----.---•-•
U Nature of Repairs or Alterations—Answer when a plicable. a-�T._`h__5 -------- �.
�.�..•..
-•-•---•-•••--•------•-••••• � ��= rc< S•7 �►.------ } S `��----------------•------------------•---------------------------------------------
J ,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System iri accordance with
the provisions of TITLE 5 of the State Environmental Code—The.undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued b �he_board ofh�alth.
/X f Q / 1
Signed . _.- `0. �d—
...... ............................... ................ ................Date-.....�
t'i ...------
Application Approved BY -! ....--- - t_ A !L� (���'_ ................- ........................................
Application Disapproved for the following reasons ...............................'....................................................................................................Date
��. Date
Permit No. �--..........
............. Issued
i Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ger#ifi ate of C omplian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by --------------------------------------------�' ...... ..............................................................----_----..........................----------
Installer
at . [--(a
....��.--------.. --------.. -
----------------------------
has been installed in accordance with the prdvisions of TITLE 5 f e St ronmental Code as described in
the application for Disposal Works Construction Permit I dated ................................................
- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- - ------------ -----------/_.>•. �` ... Inspector ........
c
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� TOWN OF BARNSTABLE
FEE.... ...
Miposa1 Works T.P.Mnstr ion .anti#
Permission is hereby granted....................... n r �--`-`-�--`=?•••• C.A = ----------•---•- ---------•-•---
to Construct or Repair ) g p y( ) p (��a.n Individual Sewage e Disposal System � v
at No.................................................1--L_Z-----••---t^_4.a �.!�----1-` s
J I Street V
as shown on the appli tion for Disposal Works Construction P rmit No_ � at@sd.................
� - �r
- x
l�l....� ........ �/v Board of eaih�
DATE..---�..... ..
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE r
LOCATION _�� all) ���,�� SEWAGE #
VILLAGE c,�4tsl. ASSESSOR'S MAP & LOTQ
INSTALLER'S NAME & PHONE NO. "Ig- L.04f¢/�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) °-C � 7� (size)
NO. OF BEDROOMS PRIVATE WELL OB'CICT�R
BUILDER OR OWNER t vv%, �,je�r40 6
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 9 - :2n
VARIANCE GRANTED: :Yes No ��
nS f'
2s�
a
U
----------------
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