HomeMy WebLinkAbout0091 HOLLY POINT ROAD - Health 91 Holly Point Road
Centerville , P
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152113 ORA 100/6 P2
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vommonwealtlh of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
( 91 HOLLY POINT RD
Property Address
ROTH
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7/10/12
eve a Cit ToTown -
every e.P 9 `� 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: A. General Information
When filling out ' p
forms an the
c h
omputer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
curthe
- et not
use nsp ector -
use the return Name of I
key. DOUGLAS A BROWN INC
Company Name
� P.O. BOX 145
Company Address
CENTERVILLE MA 02632
1B°e" Cityrrown State Zip Code
5084204534 SI A
4297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DER approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes - ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/10/12
Inspector�Ignature 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 ,�
U -
t5ins-09/08 Title 5 Off�ci I s on Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 HOLLY POINT RD
Pf,eperty AddFess
ROTH
Owner Owner's Name
information is 02632 7/10/12 CENTERVILLE MA
required for _
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
CXI 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
CESSPOOLS MEET MINIMUM PASSING REQUIREMENTS AT TIME OF INSPECTION, BOTH
POOLS WERE EMPTY AT TIME OF INSPECTION MAIN POOL COVER IS TO GRADE, CAUTION
WHEN WORKING AROUND CESSPOOLS WITH MACHINERY. OWNER IS CONTEMPLATING
LANDSCAPING BACKYARD. I WOULD RECOMMEND UP GRADING TO TITLE5 BEFORE
SPENDING MONEY ON LANDSCAPING
R) 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):
t5ms'09/08 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
91 HOLLY POINT RD
FfepeFc`y Address
ROTH
Owner Owner's Name
information is
required for CENTERVILLE MA_ 02632 7/10/12
every page. Cftyrrown State T Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break Gut 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):
I^1 distribution box is leveled or replaced F-1 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•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 11
voPiTimonwealth of IMassachuseiw
Title 5 Official Inspection Form
I�l Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments
nts
91 HOLLY POINT RD
Rrepertr Address
ROTH
Owner Owner's Name
information is
regL,Irs4.fQr CENTERVILLE MA 02632 7/10/12
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 r1k;rih�tion hnx a,,pVe oi-itlat invert d1le to an pye,,rina0—4
or clogged SAS or cesspool
El Liquid depth in cesspool is less than 6" below invert or available volume is less
' 1°" than '/day flow
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
� Cf;imlmcnweaith cf Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
91 HOLLY POINT RD
RFaperiy AddFess
ROTH
Owner Owner's Name
information is CENTERVILLE
required.fer. MA 02632 _ 7/10/12
every page. Crtyrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑, Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
Ell 6ZI 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.
Z' Any,Portion uf-8'DC33pvurOr privy-i3=witrtiry'8•cvrtC r.ur,&pululi:werl:
n 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
_
�y►
.___ a_ rr.
�es�'Pi�3=sti3•i#-$�`ie iiveii-iiv�iter a��niysis pC c3nt-'iied at
a� �icr verefled
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 20009,pd-
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
I� ❑ 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 vQtj have answered"yes" to any question in Section E the system is ontiidered a signif ant 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 n
t5ins•09108
Title 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
' M 91 HOLLY POINT RD
Property Address
ROTH
Owner Owner's Name
information is CENTERVILLE
regWred fsr _ MA 02632 7/10/12 _
every page. Cltyrrown 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?
11 L1 h I 1 flaws
♦1.. a 1 7
U nasal the system ii eoeived, lormai Haws Ir r the Pl-eviou3 t o week period
Z 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)
E 1. Wa 'the
[ cij;lt. ...J. 11..... :-11-0 feud 11ur signs-
L...-wa k
LJ' Was (I IC. I'aonrey or uwcuu Iy Irl�pectcu rvr �lyrla•vr acwage`back up?'
® ® Was the site inspected for signs of break out?
❑. ® Were all system components, excluding the SAS, located on site?
leis._ ,� _ �: _
Ipl LJ` Were'tlie Septic tt-Ink-Manholes unncovereu-, opened, and �le-interior i3f 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:
Z ❑ 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:
lU-11ber of vcui vvms kucsi n 3
l g 7 3. Nut Ib'cr of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 330
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 HOLLY POINT RD
Freperetr Address
ROTH
Owner Owner's Name
information is
rgn�ira�i,fgr CENTERVILLE MA 02632 7/10/12
every page. Cityrrown
State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF 2 CESSPOOLS
Number of current residents,:
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(last 2 years usage(gpd)):
Detail:
2010---------178 2011--------209
Sump pump?
❑ Yes ❑ Na
Last date of occupancy: CURRENT
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
lnlater meter readings, if available:
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachuse«s
Title 5 Official Inspection Form
Subsurface Sewage Dis osal System Form -Not f P Y or VoluntaryAssessments
M y< 91 HOLLY POINT RD
rFepeky Address
ROTH
Owner Owner's Name
information is CENTERVILLE
re-quired-,for MAC 02632 7/10/12
every page. Cltyr town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Oth—Ur(describe bel`Ow):
General Information
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:
Type of System:
❑ Septic tank, distribution box, soil absorption system,
El Single.cesspool
® Overflow cesspool
❑ Privy.
❑ Shared system Gres 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 thel/A,system by systemOperator under,contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal Page 8 of 17
wag posal System
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface
Sewage Disposal System F P � Form- Not for Voluntary- ry Assessments
91 HOLLY POINT RD
PR"FepeFty Address
ROTH
Owner Owner's Name
information is
re�;tJir€d fQr CENTERVILLE MA 02632 7/10/12
every page. City/Town � -
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
APPEAR TO BE ORIGINAL
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distanee f1't31ri private iitiater,supp1yi e111-or 8f.ivtion line:
feet
Comments (on condition of Joints, venting; evidence of leakage, etc.):
Septic Tank(locate an site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y El 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:
Sludge depth:
t5ins•09108
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
91 HOLLY POINT RD
RFapeky Addfess
ROTH
Owner Owner's Name
information is CENTERVILLE
required-'for MA 02632 7/10/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to-bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑.concrete Q metal ❑fiberglass g 0 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.09io8
Title 5 Official Inspection Forrn�Subsurface Sewage Disposal System-page to of 17
commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
91 HOLLY POINT RD
Rrepeny r'�de�re�
ROTH
Owner Owner's Name
information is
r-equire-dJor CENTERVILLE MA 02632 7/10/12
every page. Cityrrown t__ ___�
State-_ Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
{]concrete ❑metal ❑fiberglass 9 El 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•09l08
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
91 HOLLY POINT RD
RFepeky Ad Fess
ROTH
Owner Owner's Name
information is
required-.for- CENTERVILLE MA_ _ 02632 _ _ 7/10/12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of-liquid level above outlet invert 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: 0 Yes Q No
Alarms in working order: 0 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•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M y0'r� 91 HOLLY POINT RD
PFefie tr`y'Ae�e�Fr95
ROTH
Owner Owner's Name
information is CENTERVILLE required forMA 02632 7/10/12
every page. City/Town State _ Zip Code Date of Inspection
D. System Information (cost.)
Type:
.13 teaching pits number:
El leachina chambers number:
❑ leaching galleries number:
El leaching trenches number,-length:
❑ leaching fields number, dimensions.-
overflow cesspool number:
0 irinovative/alternative system
Type/name of technology,-
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PUMPING WAS NOT DONE DUE TO THE FACT THAT THE CESSPOOLS WERE EMPTY AT TIME
OF INSPECTION
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2 IN LINE
Depth—top of liquid to inlet invert POOLS WERE EMPTY
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction BLOCK
Indication of groundwater inflow El Yes ❑ No
tsins,•a4�ios
Title 5 Official Inspection Form Subsurface Sewage Disposal System,Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
91 HOLLY POINT RD
1^ib�eF't i%1t��Fe93
ROTH
Owner Owner's Name
information is
re�lirp�-d.#e. CENTERVILLE MA 02632
every page. City/Town ----- � 7/10/12
State _ Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil signs of hydraulic ydraulic failure, level of ondin
etc.): P 9, conditio n of vegetation,
t5ins-09/08
Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
91 HOLLY POINT RD
Fr6pe�y AddYC8.3•
ROTH
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 7/10/12
every page. City mown
State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Cornmonwealiri of Massachuseis
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
91 HOLLY POINT RD
Property AddFes9
ROTH
Owner Owner's Name
information is
regw. d.#or CENTERVILLE MA 02632 7/10/12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
I1 Surface water
® Check cellar
Shallow weft
Estimated depth to high ground water:
ieei
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:
Dale
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with locat 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:
BOTH POOLS WERE EMPTY AT TIME OF INSPECTION INDICATING THAT THEY ARE NOT IN
GROUND WATER
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M y� 91 HOLLY POINT RD
?raaefty A�e��ess
ROTH
Owner Owner's Name
information is CENTERVILLE required fort MA _ 02632 7/10/12
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
Inspection Summary (System Failure Criteria Applicable to Aft Systems)completed
IRI System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
�I
t5ins•09/08 Title 5 Official Inspeclion Form:Subsurface Sewage Dis posal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 1
i p TOWN OF BARNSTABLE
LOCATION 7l ®UY p#17-- &a SEWAGE#
> i AGE• C £.N T ASSESSOR'S MAP&LOT
`. e AL
'S NAME&PHONE NO: I=� 6 / f / • G3.
SEPTIC TANK CAPACFrY __ T 4-
LEAmmFACIL1Ty.(t)pe) (size)NO.OF BEDROOMS
BIIB..DER OR QWI IE,v' Al U C
PERMIT DATE: • GQMRhbWCE DATE: / - / $• C
Sepafation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
iPrivate Water Supply well and Leaching Facility (If any wells exist
on site or within 200.feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
i within 300 feet of leaching facility) Feet
Furnished by
i
O
1
Eck
REAk
i
i
i.
i
I,
http://www.town.bamstable.ma.us/Assessing/1IMdisplay.asp?mappar=252125&seq=1 7/10/2012
p TOWN OF BARNSTABLE
LOCATION ! l �a 1 �'y �o/�T SEWAGE#
VILLAGE C F T ASSESSOR'S MAP&LOT AS aJ
/tiSP Fc ail. �
R'S NAME&PHONE NO. /`) a PA N C G
SEPTIC TANK CAPACITY -S?TI c- //V S � c'C T/c- //V S � cr C T/6�
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS 1
BUILDER OR OWNER h r ti-1) £
PERMIT DATE: C-A114PbtM#EE DATE: / ?
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
sy-
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information �� -
1. Property Information: MAP 252— PARC 125
91 HOLLY POINT ROAD — CENTERVILLE, MA 02632 0�/ 6
Property Address
LINDAUER, PATRICIA
Owner's Name
23 ABBY GATE ROAD
Owner's Address
COTU IT MA 02635
City/Town State Zip Code
JAN UARY 16, 2007
Date
2. Inspector:
JAMES D. SEARS
Name of Inspector
A & B CANCO
Company Name
350 MAIN STREET t—
Company Address
t
WEST YARMOUTH MA 02673 -
City/Town State Zip Code
508-775-2800 ell
Telephone Numbers 'y
t�
B. Certification rn
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training
and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved
system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The System:
0 Passes ❑ Conditionally Passes Fails
N ds Further Evaluation by the cal Approving Authority
I ector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)
within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or
greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The
original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title S Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Y
COMMONWEALTH OF MASSACHUSETTS
F Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
91 HOLLY POINT ROAD
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
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:
B) System Conditionally Passes: N/A
❑ One or more system components as described in the"Conditional Pass" section need to be replaced or
Repaired. The system, upon completion of the replacement or repair, as approved by the Board of
Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with 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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
91 HOLLY POINT ROAD
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JAN UARY 16, 2007
Date of inspection
B) System Conditionally Passes (cont.): N/A
❑ 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):
Elbroken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: N/A
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)
(b)that the system is not functioning in a manner which will protect public health,safety and
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
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Not for Voluntary Assessments
'�M sJsv`e
Subsurface Sewage Disposal System Form
B. Certification (cont.)
91 HOLLY POINT ROAD
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's'Name
JANUARY 16, 2007
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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. G
® 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 that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
Title 5 OfIicial inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
COMMONWEALTH OF MASSACHUSETTS
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9 C
Not for Voluntary Assessments
see Subsurface Sewage Disposal System Form
B. Certification (cont.)
91 HOLLY POINT ROAD
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JAN UARY 16, 2007
Date of inspection
D) System Failure Criteria Applicable to All Systems: N/A
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
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
N/A 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
'/2 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 surface 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.]
YES No
® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd.
Yes No
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
COMMONWEALTH OF MASSACHUSETTS
F Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Vey`ob
Subsurface Sewage Disposal System Form
B. Certification (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
E) N/A-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 -
Elthe 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.
COMMONWEALTH OF MASSACHUSETTS
Z
E
Title 5 Official Inspection Form
tl nsp
Not for Voluntary Assessments
I� ye yd�
Subsurface Sewage Disposal System Form
C. Checklist
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's.Name
JANUARY 16, 2007
Date of inspection
Check if the following have been done. You must indicate "yes" or"no" as to each of the
following:
Yes No
® 0 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, including the SAS, located on site?
® Were the manholes uncovered, opened, and the interior inspected for
the condition of the 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)].
Title 5 OIticial Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
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COMMONWEALTH OF MASSACHUSETTS
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Title 5 Official Inspection Form
` Not for Voluntary Assessments
p^ Vev
Subsurface Sewage Disposal System Form
D. System Information
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
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
Number of current residents: 0
Does residence have a garbage grinder? Yes 3 No
Is laundry on a separate sewage system?[if yes separate inspection is required) Yes No
Laundry system inspected? Yes No
Seasonal use? Yes No
Water meter readings, if available(last 2 years usage(gpd)): N/A
Sump pump? ® Yes No
Last date of occupancy: UNKNOWN
Commercial/Industrial Flow Conditions: N/A
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
COMMONWEALTH OF MASSACHUSETT S
w Title 5 Official Inspection Form
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Not for Voluntary Assessments
p^ Vev
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JAN UARY 16, 2007
Date of inspection
General Information
Pumping Records: ✓
Source of Information: N/A
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:
® Soil absorption system
Cesspool
® Overflow cesspool
® Privy
® Shared system(yes or no)(if yes, attach previous inspection records, if any)
® Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
Tight tank.Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site? Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
Building Sewer(locate on site plan): ✓
Depth below grade: 6"
feet
Material of construction:
cast iron 13 40 PVC other(explain)
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
SCH 40 PVC - GOOD
Septic Tank (locate on site plan): N/A
Depth below grade:
feet
Material of construction:
® concrete ❑ metal fiberglass polyethylene other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) Yes No
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
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COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
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Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan): N/A
Depth below grade:
feet
Material of construction:
® concrete Elmetal 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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): N/A
Depth below grade:
Material of construction:
® concrete Elmetal fiberglass polyethylene other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page I of 16
COMMONWEALTH OF MASSACHUSETTS
N w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
Tight or Holding Tank (cont.) N/A
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 a copy of current pumping contract(required). Is copy attached? Yes No
Distribution Box (if present must be opened) (locate on site plan): N/A
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan): N/A
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
d
e� Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
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:
® leaching chambers number:
leaching galleries number:
® leaching trenches number, length:
leaching fields number, dimensions:
® overflow cesspool number: 1
innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)-
LEACHING IS DRY 6' DEEP WITH COVER ST 1'.
STAIN LINE APPROX 30" — NO SIGN OF OVER LOADING.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
d
4y ye�
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
Main Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert DRY .
Depth of solids layer DRY
Depth of scum layer DRY
Dimensions of cesspool 6' DEEP
Materials of construction BLOCK
Indication of groundwater inflow ❑ Yes ® No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)-.
MAIN POOL BLOCK WITH COVER AT GRADE, OUT LET TEE.
NO SIGN OF OVER LOADING —6' DEEP, DRY.
Privy (locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
COMMONWEALTH OF MASSACHUSETTS
d Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JAN UARY 16, 2007
Date of inspection
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.
*3
./ Ck ,
I �
Tide 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
— COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
C
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
91 HOLLY POINT ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
LINDAUER, PATRICIA
Owner's Name
JANUARY 16, 2007
Date of inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 18'
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:
USGS WELL 18' — BOTTOM LEACHING AT 8.
10' ABOVE USGS WELL DATA.
u b-} C RA
I �- I •
CU �5
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O /— Title i Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
No. a®O 6 Fee 84C)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for 33t5pogal i§pgtem Con.�tructtou permit
Application for a Permit to Construct( ) Repair(l�pgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
se or's Map/ParceI EA-er 9 / /SIG f L�' p/i!.°% ` _T A'T
Installer's Name,Address,and Tel.No. ��'r)7� Designer's Name,Address and Tel.No.
^o M A I
Type of Building: J`�415 Z
Dwelling No.of Bedrooms /7 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided and
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) £ �� C t /N
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by th' Board of Health. l/
S. Date 7 r
Application Approved Date 45
Application Disapproved by: Date
for the following reasons
Permit No. ��! �/ Date Issued
NO. V()o Fee 1/
THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Migo!gal *pgtem Con5tructiou Permit
Application for a Permit to Construct( ) Repair(AT1*`Upgroade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
krol /`� 5 CI /foLC P
f d/AvT �°, CN£Ry<
sseIs r's Map/Parcel C £Al '
p
„SaitY / -Q�Q °' i
Installer's Name,Address,and Tel.No. n 7S Designer's Name,Address and Tel.No.
� �Ca
Type of Building:
/,/o,vs
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria(/ )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) F ®� C F O'V 4/Al /V
Date last inspected:
Agreement:
1
The undersigned agrees to ensure the construction and maintenance of the afore described on-site.sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of j
Compliance has been issued by th' Board of Health.
Sign-et Date
y _ s o 6
Application Approved 15. T Date
Application Disapproved by: Date
for the following reasons
P Permit No. 6 Date Issued �Tz 6
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( L-)- Upgraded ( )
Abandoned( )by ✓/� ��
at H O 0001 iV T A C ti� has been constructed in accordance
with the provi ions of Title �and for Disposal ystem Construction PermitNo. ���6 y(� "dated
InstallerYL.e Designer
#bedroom Approved design flow gpd
The issuance of this permit shall
ynott be construed as.a guarantee that the system will,fundion-as designed.
Date "'�!J, � Inspector
————————————————————————————————————————————
No. 1/ C)o(0 — yG Fee /V G
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS
igpoal:*ps�tem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( L-)"' Upgrade ( ) Abandon ( )
System located at / �O�L S' �0/ti7- IP (' tiT
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Constr u ct: m rt be completed within three years of the date,/Ofthis pe it.
Date `T 7m Approved\b
TyO�WN OF BAMSTABLE
F* f1
.00ATION 11 0AZ Aar't-2 /Ph SEWAGE #
t
VILLAGE C'��T ASSESSOR'S MAP & LOTLS Z f °L<
-'INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
�'���e
LEACHING FACII.ITY: (type) 5 Z c-
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ��
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COMMONWEALTH OF MASSACHUSETTS
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EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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a a DEPARTMENT OF ENVIRONMENTAL PROTECTION
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350 MAIN STREET
WEST YARMOUTH fMA,
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION '
MAP 252-PARC 125 '
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632 �W
Owner's Name: SELIG,CHERYL (~,
Owner's Address: 91 HOLLY POINT ROAD err'
CENTERVILLE,MA 02632
Date of Inspection JANUARY 11,2005
.. r ;
Name of Inspector:(please print) JAMES D.SEARS r kt
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
•� Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: ! l 99-f
The system inspector shall s9n,64 opy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of comple:iug 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 tl c system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG,CHERYL
Date of Inspection: JANUARY 11,2005
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 CUR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
_ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exflltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11,2005
C. Further Evaluation is Required by the Board of Health:N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the systenis
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
* This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11,2005
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
✓ 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
N/A 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 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 coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes" or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—f WPA)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 is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
L__
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11, 2005
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?
If Were all system components,excluding the SAS,located on site?
If Were the manholes uncovered,opened,and the interior inspected for the
condition of the 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)has been determined based on:
Yes No
✓ 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(3Xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11,2005
FLOW CONDITIONS
RESIDENTIAL-✓
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2002-62,000 GAU2003-50,000 GAU2004-49,000 GAL
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: JUNE 2004
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ soil absorption system
T cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11,2005
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 6"
Materials of construction: Cast iron ✓ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to the bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal _ fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11,2005
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANUARY 11, 2005
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.)
LEACHING IS ONE(1)1000-GALLON PIT 2'WATER,STAIN LINE AT 30".
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
MAIN CESSPOOLS: (cesspool must be pumped as part of inspectionXIocate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert: 4"
Depth of solids layer: 4"
Depth of scum layer: 0"
Dimensions of cesspool: 6'DEEP
Materials of construction: BLOCK
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
MAIN POOL BLOCK WITH COVER AT 1",POOL AT WORKING LEVEL OUTLET TEE,NO SIGN OF OVERLOADING.
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15,2000 9
Pa e - .
10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG, CHERYL
Date of Inspection: JANCTARY 11,2005
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.
O
i I
Title 5 Inspection Form
Page 1! of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,,;,
Property Address: 91 HOLLY POINT ROAD
CENTERVILLE,MA 02632
Owner: SELIG. CHERYL
Date of Inspection: JANUARY 11, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 18, feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 1_50 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:
USGS WATER 18'.
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VILLAGE ASSESSOR'S MAP& LOTV
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
ter-
51£C/T
LEACHING FACIL=: (type) J /�//�- (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between.the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
ry on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by Chr/V C ®
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1-0 C A-T ION SEWAGE PERMIT NO.
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INSTA LLER'S NAME i ADDRESS
S U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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