HomeMy WebLinkAbout0031 HARRISON ROAD - Health 31 Harrison Road
Centerville - - - -
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,ig Title 5 Official Inspection Form
I. a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name /
information is required for every Centerville V Ma 02632 9/24/2020
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. Inspector Information 61-iF /4 9
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Company
A Lane
Co
� Company Address
Centerville Ma 02632
Citylrown State Zip Code
774-248-4850 smjonestitle5@gmail.com, SI4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails zz�
9/24/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
rn Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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 property located at 31 Harrison Rd Centervill is served by a Title V septic system consisting of a
1000 gallon septic tank and a 1000 gallon precast leach pit. Although the system was found to be in
proper working condition at the time of inspection this report does not guarantee future performance
under similar or increased usage.
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
fo
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
r= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yy
M ,tl 31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Tank pumped at time of inspection
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? size of tank
Reason for pumping: routine maintenance
t5insp.doc•rev.7/26/2018 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
1000 gal septic tank, 1000 gallon precast leach pit
Approximate age of all components, date installed (if known)and source of information:
1986 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: varies
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.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�o
-� 31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3
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 gallons
Sludge depth:
5"
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
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 pumped after inspection and should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
Outlet cover is on a riser
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1 yy
31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M e 31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1x1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M. 31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is Centerville Ma 02632 9/24/2020
required for every
page. City(Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was video inspected from septic tank and was found dry with a stain line approx 2'from
bottom.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
I
t5insp.doc•rev.7/2612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia (Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Harrison Roadq
Property Address
Cynthia(Silbor) Harrison
Owner Owner's Name
information is required for every Centerville Ma 02632 9/24/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector.
Frank Nunes III
Name of Inspector
saa
Company Name
25 Deer Ridge Rd
Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508.272.6433
Telephone 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 CHAR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
A. �aldv Y'
10/1/09
Inspector gna ure Date F O
The system inspector shall submit a copy of this inspection report to the A ving AU$o ' oard.
of Health or DEP)within 30 days of completing this inspection. If the system is a shared sysn or
has a design flow of 10,000 gpd or greater, the inspector and the system' er shall s&bmit*e
report to the appropriate regional office of the DEP. The original should be nt to thesysteftowner
and copies sent to the buyer, if applicable, and the approving authority.
*""*This report only describes conditions at the time of inspection and un r the cgjpidRIgA of use
at that time.This inspection does not address how the system will perform in tilt futM under
the same or different conditions of use. n
4v I
f
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
City/Town State Zip Code Date of inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Pumping suggested every 3 yrs to prolong the life of the system. Pumping suggested at this time
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.
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 exttration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ 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
` Commonwealth of Massachusetts
U1119 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1109
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health(cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
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
❑ ® 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.
Commonwealth of Massachusetts
a,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® 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 6 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 GMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'e 31 Harrison Rd
Property Address
Tanca
Owners Name
Centerville MA 02632 10/1/09
Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no'as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°l 31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
Citylrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): n/a 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: 0
Does residence have a garbagegrinder? Yes No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: April 09 per
realtor
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: unk
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):
No D-Box
Approximate age of all components, date installed(if known)and source of information:
1986 per BOH file
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
Commonwealth of Massachusetts
' n Form
Tale 5 Official Inspection
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
City/town State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
3'6"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 3'
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
No risers
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000g
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle >12"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No D-Box
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(locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: 0 Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 1011/09
cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® 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.):
Pit is 2'6"below grade, it is dry at this time,stain line at the 2/3 full mark, no indication of past backups
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 10/1/09
Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
C � - d
� s �
� O
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Harrison Rd
Property Address
Tanca
Owner's Name
Centerville MA 02632 1011/09
citylrown 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: >10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Shot w/site level of nearby pond puts GW at> 10'
COMMONWEALTH OF MASSACHLSETTS
_ r E�iECL TIVE OFFICE OF E:�'VIRON MENTAL AFF AJRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r 4� ONE RZ\TER STREET. BOSTON hLA 0210c (61'1 292•550i
TRi.DY C01:
Secre:an
ARGEO PAUL CELLLICCI DAVID B STR'-*HS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 31 Harrison Rd.. r Name of Owner Jerry Dunning
Centerville Address of Owner:
Date of Inspection: ��•-- ,'- ��
Name of Inspector: (Please Prinn)Wm. E . Robinson Sr .
I am a DEP approved system inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
rit copany Nm ae: Wm. E . Robinson 1eptic Service
Mailingaddress: PO Box 0 9. Centerville . MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: •wry Date: 7—"
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow,of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
APR 14 2400
ToW'VOf
NEAT HE ps pTlF
j r�+
rev1sed 9/2/98 Page Ioru
n
• f^!ed on Recvc;rd Pane,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART A
CERTIFICATION(continued)
"ropertyAddress:31 Harrison Rd.. , Centerville y
Jwner: Jerry Dunning
Date of Inspection:
INSPECTION SUMMARY: Check B, C, or D:
A. SYSTEM PASSES:
I/ I have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. YSTEM 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.
Indicate es, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
revised 5/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
t
CERTIFICATION Icorrtinued)
Property Address: 31 Harrison Rd.. , Centerville
owner: Jerry Dunn
Date of Inspection: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 the
ublic health, safety and the environment.
1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
1 OTHER
e
revise 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 31 Harrison Rd.. , Centerville
Owe: Jerry Dunning
Date of Inspection: zy—
D. S FAILS:
You must i dicate either "Yes" or "No" to each of the following:
I ve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
de rmination is identified below. The Board of Health should be contacted to determine what will be necessary to correct,the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You mus indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public
water supply well)
The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of th Department for further information.
revised 9j 2/98 PaRr4ofII
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Prop"Address:31 Harrison Rd.. , Centerville
Owner: Jerry Dunning
Date of Inspection: 4' _,
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks an&the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with NIA.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at
b� P B.O.H. ,
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
11.5.302(3)(b)]
_ The facility owner land occupants,if differeru from owner) were provided with information on the propermaintenaacof
SubSurface Disposal Systems.
rev- d 9j2/98 Pagc5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Irop"Address: 31 Harrison Rd.. , Centerville
Owner: Jerry Dunning
Date of Inspection: C/v'7—0--,
FLOW CONDITIONS
RESIDENTIAL:
Design flow:aL C1 g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow 3 C 0
Number of current residents:
Garbage grinder lyes or no): A, O
Laundry(separate system) (yes or no):/1 0, If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):-A-10
Water meter readings, if available (last two year's usage(gpd): 1999 130, 000 aal.
Sump Pump(yes or no): /L O 1998 72, 000 gal.
Last date of occupancy:�2 0-0
COMMERCIAL/INDUSTRIAL:
Type o establishment:
Design ow: gpd ( Based on 15.203)
Basis of esign flow
Grease t ap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Wate meter readings, if available:
Last d to of occupancy:
OTHE : (Describe)
Last ate of occupancy:
GENERAL INFORMATION
PUMPING RECORDS ands urce of information:
/ 9 - / � c)--c) / 7 � � e 4*4 G X '.
System pumped as part of inspection: (yes or no)_`
If yes, volume pumped:_gallons
Reason for pumping:
TYPE 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information: 9 576
Sewage odors detected when arriving at the site: lyes or no) AG 0
revised 9/2/9- Page 6of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontimmd)
'TopertyAddress: 31 Harrison Rd.. , Centerville
Owner: Jerry Dunning
Date of Inspection:
BUILDI G SEWER'
(Locate o site plan)
Depth bel w grade:_
Material o construction:_cast iron_40 PVC_other(explain)
Distanc from private water supply well or suction line
Diamete
Comme ts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: I
Material of construction: t 'concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance (Yes/No1
v 99 � ► r�
Dimensions: / je
Sludge depth: 73 —
Distance from top of�sludge to bottom of outlet tee or baffle:
Scum thickness:/i;1-
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom141of outlet tear or baffle:��
How dimensions were determined: 6 O t,`�
'omments:
(recommendation for pumping, condition of inlet and outlet teess r baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) /0 b fl D / J ib �C S J ,D/.� ✓✓
GREA TRAP:
(locate o site plan)
Depth belo grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimension
Scum thic Hess:
Distance rom top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of ast pumping:
Comm nts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidenc of leakage, etc.)
reused 9/2/98 Page 7of11
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Jrop"Address: 31 Harrison Rd.. , Centerville
Owner: Jerry Dunning
Date of Inspection:
TiG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dime ' ns:
Capacit gallons
Design flow: gallons/day
Alarm present
Alar level: Alarm in working order: Yes_ No_
Date f previous pumping:
Com ents:
(cond ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan) l
Depth of liquid level above outlet invert:��1
Comments:
Inote if level and distribution is equal, evidence of))s lids carryover, evidence of leakage into or out of box, etc.)
Q 1�
PUMP HAMBER:_
(locate n site plan)
Pumps n working order: (Yes or No)
Alarms in working order(Yes or No)
Comm nts:
(note ondition of pump chamber, condition of pumps and appurtenances, etc.)
revises 5/2/98 Page 8or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 31 Harrison Rd.. , Centerville
Owner: Jerry Dunning
Date of Inspection: a--o
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits; number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Altemative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure level of ponding, damp soil, condition f ve tation, eta.)
d A
CES OLS:_
(locate o site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of s lids layer:
)epth of s um layer:
Dimension of cesspool:
Materials f construction:
Indicatio of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comment
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Material of construction: Dimensions:
Depth solids:
Comme ts:
Inote co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
�2ViSe: cj�L�7C Palzc9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
"Iroperty Address:3 1 Harrison Rd- , Centerville
owner: Jerry JD inning
Jate of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
,/{aG
� 1
P
ti
—1
revised 9/2/9E Page 10of11
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icorttinued)
roperwAddress: 31 Harrison Rd,. , Centerville
Owner: Jerry Dunning
Date of inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow. Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater /3 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revise ' 9/2/96 Page 11of11
,iSSESSORS MAP NO:
PARCEL NO.: —_— ——---
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.........................................O F..........:.............................--------------------..............----•----•--..--
Appliration for Di-qVlvii al Works Tonstrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ()<) an Individual Sewage Disposal
System at:
.- • ---------- ------- -----------------------------------------------------------------------------------------------•--
Location-Address or Lot No.
.V.j...C........... .................................................................................................
/ Owner Address
------.... -•---�:o t1 it---V--I'---e-� ��' h
- --------------
Installer Address
Type of Building Size Lot....../_,11_A_o:v..Sq. feet
V Dwelling—No. of Bedrooms........ ................. .. _Expansion Attic ( ) Garbage Grinder ( )
PLO Other—Type of Building ............................ No. of persons-_-___.__-__-____-_--_______ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter_............. Depth----------------
xDisposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'—' Percolation Test Results Performed b
a Y-------------------------------------------------•----.....--------------- Date.......................................
-a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-___-_-__-___-•-_-_-_.
0 Description of Soil........................................................................................................................................................................
x
�.,
W ••----•-----------------•------•••-•••---------......•••--•-•--••••--••-••----•-----•••---•-••---•-•-••--•- �{n
U Nature of Repairs or Alterations—Answer when applicable--------
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I--I
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued by the board of health.
Application Approved at
at '��
•.....
Application Disapproved for the following reasons:...........................................
-------------------------------------------------•--•-------••-•------------------...--------------•--..._....-•--------•----------------------------------------------.................................
Date
Permit No.------ -----------•! Issued-..................................
Date
TOWN OF BARNSTABLE
LOCATION SEWAGE # - ► r�j
VILLAGE ASSESSOR'S MAP & LOT ')A q d
` INSTALLER'S NAME & PHONE NO. �/� , � z.vc%a B 71. G S cp
I
SEPTIC TANK CAPACITY
I
LEACHING FACILITY:(type) /,0ao ,tom,(47EaAl (size) /A 4.
I
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER !Q R �.A �i Ia / �' Al ,-
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
143 �
Jr�
NO3v� 6 Fres.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................................OF.......................................-_...------------------................_..._....
Appliraiilau for Diiposal Works Towitratrttou Fautit
Application is hereby made for a Permit to Construct ( ) or Repair k) an Individual Sewage Disposal
System at:
Location-A dress •---.- -- ._•.-••.-- •-_-._-_•.--or•Lot No.
`ti'• — �X4 -. ,ec 3 .... ...............•--•••.........................
Owner Address
Insta:ier Addr s
dType of Building Size Lot---�_ ,f__� __.Sq. feet
Dwelling—No. of Bedrooms........._.•_ .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _____________•_._-.•-___._- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -----•-''--•----••......--••••-- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
f� Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit..._................ Depth to ground water.........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix .......'--'•-•---•............."•"-•--•-•-••..........•-••-.................------...-------••••-•..........................................
.....
.---------
0 Description of Soil.......................................................................................................................................................................
x
V
W
x ----.-
U Nature of Repairs or Alterations—Answer when a plicable__._... l o P__._ _____
...... x-' $ .
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of - . ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'slued by the board of health.
8 ;:;....__.-�''.....................
Application Approved ! �?1 -
r C ----
ate
Application Disapproved for the following reasons:--'•----•••---------"-•------------'------------------------'-'•'----•---'------------------- --------------•-
.........••-'••••--'•--•......-•••--•-••-•'---•-----•--•._.---'--••-•-•-•.........................•--•--•I-••----•-----•-----••---••-•-••-•--•--•...'--"-.."'•-••-•••••-•-----"-'-••'...........------
Date
PermitNo.... ------- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�w n, , .
OF.......... .a................ .= ................................
Trrtif irtttr of TI-Im haatta
THIS IS•TP CERTIFY, hat the Individual— ewage Disposal System constructed ( ) or repaired ( )
by �.' � ............. . . ...:� --= .---------•----------------------------•--------------------------------
��_ Installer
at ... -- 2-qt,_w............
has been installed in accordance with the provisions of T i T LI':. j of The State Sanitary Code as6described in the
-� j/3^..
application for Disposal Works Construction Permit No��-__�a-:_.i_�1.�_ dated-...-_-"�.. ..�___=__��--.__.--_-_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL F�J1PI � SATISFACTORY.
DATE...................`..(..._.._...... .................................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
-- ---BOARD OF HEALTH
a
............................. .-�.`..N.oF...............�-=:�...?::..._:.�-----....................................
FEE. ':... ........
�io�o��al rk� �a� - #rttr�iou leruti�
Permission is hereby granted • •••`-�.(�?�........_ h :��..._.......•--'------•--•----••--'--•---....---•-••---....--
to ConstrIa.ct,_� ) or p 'r ( ) an Individual Sewage Disposal" System
r------------------ •-r. - �
te
as shown on the application for Disposal Works Construction Permit No`.'��` ._016 Dated............. ........ ......
Board of Hea••-1 K i
FORM 1 �35 HOBBS & WAR EN, INC., PUBLISHERS } "