HomeMy WebLinkAbout0020 HI-ONA HILL ROAD - Health (2) 20 HI-ONA HILL, CENTERVILLE
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Commonwealth of Massachusetts o?Ug—080- OOa--
�v Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Hi-Ona Hill Road ;
Property Address f,!
Dino Chiavegato `y
Owner Owner's Name l
information is required for every Centerville y MA 02632 08/25/2020
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
p e filling out forms A. Inspector Information 5 —17110(p
/y
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
ray Company Address
Teaticket Ma. 02536
City/Town State Zip Code
ran 508-280-3356 S13938
Telephone Number 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 15.000); 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. 0 Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
08/25
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
i
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u�
20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is
required for every Centerville MA 02632 08/25/2020
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:
This 2 bedroom home has a 3 bedroom design system. The system has an H-10 1000 gallon septic
tank with an H-10 D-Box feeding 6 infiltrators. At the time of the inspection no visible failure criteria
was found.
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.& Massachusetts
�v Title 5 Official Inspection Form
l0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. Cityfrown 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 FIND (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
�n Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u � 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.; � 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
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 fh 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.
El Z 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
lg. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
,page. CitylTown 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
IT Title 5 Official Inspection Form
ti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes El 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 ears usage town water
9 � Y 9 (gPd))�
Detail:
In 2019-6000 gallons were used and in 2018-5000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Hi-Ona Hill Road
u
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
14*1
Commonwealth of Massachusetts
�n ►(!A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Hi-Ona Hill Road
u
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
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):
Approximate age of all components, date installed (if known) and source of information:
New system 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
"
Depth below grade: 41feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. town water
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
I
Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I;
20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
a e. City/Town State Zip Code Date of Inspection
P9 P p
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 32"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:
H-10 1000 gallon
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle 34"
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
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
I
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.�� 20 Hi-Ona Hill Road
u
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. CityrTown 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 oil
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
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
�1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Hi-Ona Hill Road
u
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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:
® leaching chambers number: 6 Hi cap
infiltrators
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. Cityrrown 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.):
At the time of the inspection no visible failure criteria was found.
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.):
t5ipsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ 20 Hi-Ona Hill Road
V
Property Address
Dino Chiavegato
Owner Owner's Name
information is
required for every Centerville MA 02632 08/25/2020
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
d6fi mi-o-nwealth'd Massachusetts
Title' 5- dff c al I`n�s �`ect ons For-i�,;
-� Ip .
Subs dace Sewage Dispo""sal System Form'-Not for Volunfary'Asse`ss'merts�
20 Hi' ria'Hill'Roa&
Property Address
Din&Chiavegato
Owner Owner's Name
information is
required for every Centerville MAC__ 02632',_ 08/25%2020 _
page. Cityfrown _ - _.State` Zlp_Code' Date'oflnspectlon�
D. Systernlnforlmation(contj'
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
fK6 building.'Check one of the boxes below:
Z hand-sketch in the area below
E]r drawing attached separately -
LI
_ 6
41
° o
f, 3
l5insp.doc•rev.7/26/2018 Title 5 Official'inspection Form:Subsurfaee'Sewage Disposal System•'Page 16 of 18
Commonwealth of Massachusetts
�v = ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
f'
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 20 Hi-Ona Hill Road
Property Address
Dino Chiavegato
Owner Owner's Name
information is required for every Centerville MA 02632 08/25/2020
page. City/Town 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
F
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every 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 A. General Information
forms on the j (I f
computer,use 1. Inspector. l�
only the tab key
to move your A.Riker
cursor-do not Name of Inspector
use the return
key. R.L.C. _
Company Name - ^3
P.O. Box 726 -n
Company Address v 03
South Yarmouth MA r 02664 %a
City/Town State y Zip Code
508-776-6460' S14590
Telephone Number License Number r
co s rt
B. Certification
1 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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
/J
— 07/01/2011
Ins is Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP::The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage I System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owners Name
information is required for Centerville MA 02632 06/29/2011
every page. Ciryfrown 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:
System was inspected to be in working condition at time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N,ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiftration 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):
t51ns•09/W 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
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/Town state Zip Code Date of Inspection
B. Certification (coat.)
B) System Conditionally Passes(cunt):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipes)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09f08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/rows State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 overioaded 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 4/z day flow
t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is
required for Centerville MA 02632 06/29/2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (Cont.)
Yes No
❑ Z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ 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.
tsins-ogros
Trite 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD
t5ins•0901 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 3 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ 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 Vast 2 ears usage 0 unavalible
9 � y 9 (gP�)�
Detail:
property has been vacant with no recorded usage
Sump pump? ❑ Yes ® No
Last date of occupancy: unk.Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/town State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Barnstable Treatment
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: 1000
gallons
How was quantity pumped determined?
Truck operator
Reason for pumping: maintence
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/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed (d known)and source of information:
Installation 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5feet
Material of construction:
®cast iron ❑40 PVC ❑ other(explain): interior pipe hard to inspect due to
poor crawl space acess
Distance from private water supply well or suction line: Town Water
feet
Comments (on condition of joints,venting,evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon precast concrete tank with PVC T'ys
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5'x5'x9'
Sludge depth:
7"
t5ins•09/W Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. city/town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 27"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Sludge Judge —
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank had no defects observed at time of inspection.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
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-09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property _
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert equal at inverts
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.):
no evidence of carry over or out of level box.
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.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins-Og= ritie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official- InspectionFora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
® leaching chambers number. 6 Hi cap
Infiltrators
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovative/afternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation,etc.):
soils above S.A.S.indicated no signs of effluent seepage or past introduction.
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•09MB Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fortin
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. City/Town 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•09/W Title 5 Official Inspection Form:Subsurface Savage Disposal System•Page 14 of 17
y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
_Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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
W.
n�
o
-3 Js`
.31.2
t5ins•09M Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10 no 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: 3/18/1994
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
records on file
❑ Checked with local excavators, installers-(attach documentation
® Accessed USGS database-explain:
over 30 feet.
You must describe how you established the high ground water elevation:
Records on file at Board of Health and topo map with USGS. Property is located on elevated lot of
land.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•09MB Title 5 Official Inspection Form:Subsurface Smage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
20 Hi-Ona-Hill
Property Address
Bank Property
Owner Owner's Name
information is required for Centerville MA 02632 06/29/2011
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary:A. B,C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Y�
2-0
TROY WILLIAMSVEO
SEPTIC INSPECTIONS �E�E
:_:
Certified by MA Department of Environmental Protection •IMOFB (508) 385-1300
19 Hummel Drive
iEhUH OFPL
South Dennis,MA 02660 6
17
Aj
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 1117,292.5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: aO N I -Utoc.- ^c( Name of Owner y Io,c( �w r a...t 4N 0-ve-
Co_o 4 �; (I� Address of Owner: 7 K Y
Date of Inspection: /O/1/cI 9 Ale-t✓f b 1, /0
Hartle of Inspector:(Please Print) Trey Williams
I am a DEP approved system inspector pursuant to Section 15.340 of Trtle 5(310 CMR 15.000)
Company Name: Troy wlliams Snntic Inspections
Mailing Address: 19 Hummel'Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT
1 certify that 1 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 n /
inspector's Signature: / (N 2 Date: /0// 69,
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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the.system on the Date of
Inspection noted above.
revised 9/2 /9F? P.— I r I I
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: 20 Hi-Ona-Hill,Centerville,MA
Date of kupeCb0n: Maya&Vladimir Pave
October 1, 1999
INSPECTION SUMMARY: Check A, B. C, or D:
A. SYSTEM PASSES:
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. SYSTEM CONDITIONALLY PASSES: V1
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 yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a 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
revised 9/2/98 Page 2of11
�i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop,,W Address: 20 Hi-Ona-Hill,Centerville,MA
Owner: Maya&Vladimir Pave
Date of Irupection: October 1, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/,
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
Public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WfTH 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 60 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).
3) OTHER \
revised 9/2/98 Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
20 Hi-Ona-Hill,Centenille,MA
PrOP"Address: Maya&Vladimir Pave
Owner- October 1, 1999
Date of Inspection:
D. SYSTEM FAILS: NIII
You must indicate either "Yes" or 'No- to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day now.
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 feat 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:/1/l/g
You must indicate either "Yes"or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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=IWPAI or a mapped Zone If of a public
water supply well)
The owner 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 the Department for further information.
revised 9/2/98 Page 4or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Hi-0na-Hill, Centerville,MA
owner: Maya&Vladimir Pave
Date of k--pection: ()CtOUer 1, 1999
Check if the following have been done: You must indicate either 'Yes-or -No- as to each of the following:
Yeses No
Pumping information was provided by the owner,occupant,or Board of Health.
4 (,Sc C 6 C C 0'0" y
None of the system components have been pumped forat least two weeks and-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.
Y _ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
1L/ _ All system components,excluding the Soil Absorption System,have been located on the site.
Y _ 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.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable( .
/ [15.302(3)(b))
JC - _ The facility owner(and occupants,if different from owner)were.provided with information on the.propermaintenanceof SubSurface Disposal Systems.
revised 9/2/98 Page sorit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 20 Hi-Ona-Hill, Centerville,MA
Date of Inspection: Maya&Vladimir Pave
October 1, 1999
FLOW CONDITIONSRESIDENTIAL:
Design flow: PO g,p,d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow6
Number of current residents:
Garbage grinder(yes or no): NG
Laundry(separate system) (yes or no):A/0 ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):�g
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no): NO /zo
Last date of occupancy:O c- . >'.u—r_1 v S e 6 + '�'• i 'r 7►+�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_ Qpd (Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Title 5 system:(yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Lest date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: I
NO D Jill rn v i.� 1 e -J w. Cr.b C. v v�c�t�6 i
T
Sys4em pumped e�part of inspection:(yes or no) No
If yes,volume pumped: gallons
Reason for pumping:
TYPE pF 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,data installed(it known)and source of information: <.
Sewage odors detected when arriving at the site:(yes or no) /Vo
revised 9/2/98 Page 6of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPECTION FORM
PART C
SYSTEM?JFORMAMN(contirxred)
Property Address:
Owner: 20 Hi-Ona-Hill, Centerville,MA
Dace of Inspection: Maya&Vladimir Pave
O
BUILDING SEWER: October 1, 1999
(Locate on site plan)
een
Depth below grade: �O
Material of construction: cast iron Z40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition� of' ints, venting, evidence of lelakage,etc.)�n t t W G✓L- .� L� G/ cam.✓ !.�T �/'h t o T �n S . .-.. .
SEPTIC TANK:
(locate on site plan)
Depth below grade: /
Material of construction:_Z.oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age ls.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: S 'x 9' 'X 6 /00 fc F//u•�
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: Nun/r
Distance from top of scum to top of outlet tee or baffle:Afd Distance from from bottom of scum to bottom of outlet tee or baffle: A/d
How dimensions were determined:
Comments:
(recommendation for pumping;condition of inlet an outlet toes or baffles,depth of liquid level In relation to outlet•nvert,structur"tegrity,
evidence of leakage,etc.) L 4' ✓
• ., I e—�— a H cJ, o U 4- c 4-
A m o I h-e e—
GREASE TRAP:
llocate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrtinued)
Property Address.owner: 20 M-Ona•Hill,Centerville,MA
Data of Inspection: Maya&Vladimir Pave
October 1, 1999
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions ------ -• -.__.
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert: I e-y v�
Comments:
(not level and distribution Is equal,evidence of solids carryover,evidence of leakage Into or out of box;etc.) "/ a-X L-j m.A
o✓ 12 1 �. ✓ ✓.
PUMP CHAMBER NI/9
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 page sorII
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continue<0
Property Address:Owner: 20 Hi-Ona-Hill,Centerville,MA
Date of Inspection: Maya&Vladimir Pave
October 1, 1999
SOIL ABSORPTION SYSTEM(SAS):Y
(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._&_-J-j^A 4,-o„+o,-S w; n 2 S 74
U -
leaching galleries,number:
leeching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(!n —ondition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of veg tation, etc.)
s h ,.; �t F , '
►-�rD L,is
CESSPOOLS:-,&1 A
(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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
PRIVY-_ll�
(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.)
revised 9/2/98 Page 9of II
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 20 Hi-Ona-Hill,Centerville,MA
Date of Inspection: Maya&Vladimir Pave
October 1, 1999
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)
/t>6o ycd l-"h
emu..
3a z3'
2-8t
— 3ox
. r
u•,� 2rs�h`•
revised 9/2/98 Page 10of II
4`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Hi-Ona-Hill,Centerville,MA
Owner:
Date of Irupection: Maya&Vladimir Pave
October 1, 1999
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,20fFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V Observed Site JAbutting property,observation hole, basement sump etc.)
V 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)
().5 G S 4 �p s 5 r!.o a w t'-", o, 4-
rIA••h rn V�
revised 9/2/98 Page 11 of It
L, g-o z. � (TOWN OF BARNSTABLE
LOCATION,, SEWAGE # 7' !
VILLAGE('�19Ae-`0ii Il ASSESSOR'S MAP & LOTf-�6tf-()PO
INSTALLER'S NAME& PHONE NOA1429/D W1 ( '�i'�',5!,z V,�>,p
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL O UBL1C WATER
BUILDER OR'O WNEI� t� � )'►'�E- �- tl ic � K
DATE PERMIT ISSUED: / /
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes C No�
�av�q
�rok�
30 , Z3
l
e' �
Z� 3a' ?f a�
fl
/ �
APP VED ✓�� � Li
°i"
Barnstable Conservation Department
0...._..._.. MF,CA� Fs�s..............................
THE COMMONWEALTH OF MASSACHUSETTS
stncd Bate BOARD OF HEALTH V/
TOWN OF BARNSTABLE
Appfirati n for Di�vttiittl Works Towitrnr#iun rami#
D jj � e ` J
Application is her made for Perhiit to` Construct ( ) or Repair (,>L) an Individual Sewage Disposal
System at:
..................................... �� ✓1/t/�
Lo anon;:\ddress or Lot No.
.........................!Z ........ .....Y4� ----_----------- .......................................
Owner ddress
.--0?'�-`W�-__-•----_c`..^s_. J...... .7G1� 1 ......j'!_L.../h-?.U—S.....-.
Installer Address
Type of Building Size Lot............................Sq. feet
.a Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building -------------------------_ No. of persons------------------------.... Showers ( ) — Cafeteria ( )
d Other fixtures
W Design Flow................... ._..._._ gallons per person per day. Total daily flow..--....... .........-----......gallons.
WSeptic Tank—Liquid capacityA --gallons ength---------------- Width...------------- Diameter_............. Depth----........--..
x Disposal Trench— No. ---------/........ Width--- -------- Total Length.----1 ........ 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........................................
W
a Test Pit No. I----------------minutes per inch Depth of Test Pit..----------------.- Depth to ground water........--.---..........
914 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......--.--.----........
W -----------------------------------------------------------•---•---------•--------••-•.....----••--•.........................................................
0 Description of Soil........................................................................................................................................................................
x
U -•••------------•-------••-----•--•----•--••--------•-•--------•••--•-•----•---------••••---------------••------------•-•-•---------------------•-----------•---......._---••-••-----•---••---•--__---.
W
x ----•--------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations Answer when applicable---f^1sT' A- 1 U oU �yl-r/►Z Q!ST
......................� ......--.
{... ..................�2.... ....------------------------........-----------
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 Complianc sWeenissueby board of health.Signed --------- .................. .........� ......... v/Da
Application Approved BY �� ..... ........... t"r� �'-� 'G ' .�
......... ._r......... .............
Dace
Application Disapproved for the following rea`sons.. _.... .........................::...................
------------------------------------------------------------------------------ ------------------------------------------------- ---------------------------------------------�------------------------ ........................................
�� `...� Issued ..........._�.�.......... J...P .. "7
Permit No. .......... ...
_ Dare
THE COMMONWEALTH OF MASSACHUSETTS V/
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Divjivupttl Wurkii Toutitrur#tun ramit
0 H l (in Wif
Application is hereby made for a Permit fo1 Construct ( ) or Repair (.-/) an Individual Sewage Disposal
System at: >
............................................................S L L Lam.
Location-Address G or Lot No.'
..._��-/, ._...5�..�I_-^'-�- ---------� -�-�------� ----�Q�=-�-----------2:_��......_...�_s ,................-----•------
Owner
W ,Address
GJ.................................C . .. �-•-•-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms............
--------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------------••-----------------------..._......--•-------...----------.........-•----....._--------
W Design Flow....................��~ ___-___--.-gallons per person per day. Total daily flow.......... - _--------------------gallons.
WSeptic Tank—Liquid capacity.f ..gallons L ength................ Width---------------- Diameter__..------------ Depth................
x Disposal Trench—No. .........�_....... Width_.. ----------- Total Length-----fit........ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed bY---------------------..................................................... Date.------------------------------------.
Test Pit No. I................minutes per inch Depth of Test Pit_................. Depth to ground water__-__...__.-_-___._-_.-.
LT. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
W .......................................•---------•.....--------•..........._-----............_•-----.........................................................
0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W
U
W
x ---•••-•-••------- ....... ------•-•-----------•-------••----------...--------------------------•-•----------•••--------------------•----------•------•----•----.
.............
0 Nature of Repairs or Alterations—Answer when applicable.-_i. "JS% "�.__. __._ G ou . .........................................../►-,�I�
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 P een issued)by the board of health.
Signed /G..................- --- - -�-- ----------------- ...... ..............................
Dace
Application Approved By ..:.:........ ......�.....:. t .. r'
...:........................Y.---------.... - -------------......-----------........ ...../
Dve
Application Disapproved for the following reasons:
.............. .........................----------------------------------------------------------------------------------------------------------------------------------------------------- ........................................
Permit No. r f.....i� !/....f`....,/ ... ......... Issued c .."" X! �
/ Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CEE�ifirate of (110 pliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by G l 'liGt o / 0v/j_vIns—r1,Jl-Arr uc7riGAJ
....� --------.. ---------------- -- ------------------------------------------------------------------------------------------------------------------------------
7f . � .�' " � ®: � S �' / ✓//Ls�at -----------------------------------------------`", _y..1 ... ... . ----------.. ---- --------------------- .. --------------------
has
been installed in accordance with the provisions of TITLE 5,pf The State Environmental Cocle as descrii ed in
the application for Disposal Works Construction Permit No. ._ _..._....... --- .. ....dated ........ ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE'CONSTRUEA AS A GUARANTEE THAlfTHE
SYSTEM WILL FUNCTION SATISFACTORY. L
DATE----------------------------------.. Inspector ....... ........ -------------- .............. --. �(:- ... ( .1 - - .. r
THE COMMONWEALTH OF.MASSACHUSETTS �� � 6i,:�_
BOARD OF HEALTH
'No 1 FEE----
TOWN OF BARNSTABLE �U
.------•......... ...... ...-•--•-- ......
Diupuiitt1 urkii Tuni#r utiun rantit
Permission is hereby granted--.--._..._- :----J. ._
to Construct ( ) or Repair an an Individual Sewage Disposal System
at No.
streeta.
as shown on the application for Disposal Works Construction Perm�i't�j`°o�:j�''_ ated.... '..,�.b---..-'.`.' .
................C_._._.'.._ '...___ oar _. �-------._..__....................
1. fl of Health /
DATE......'-- " '
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
2.0 L.; o�k `t TOWN OF BARNSTABLE'Ste. care azo�`�_a
7.0CATION Z y 7 � � Tool SE SEWAGE # �T/Q
'PILLAGE ASSESSOR'S MAP & LOT2-08
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY 2 -- /0 O OLl
g I��c �•��, �� ��
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
B OWNER o m
L
ERMIT ISSUED:
COMPLIANCE ISSUED:
CE GRANTED: Yes No
�a � s�
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