Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0006 HORATIO LANE - Health
OF I . , CENTERVILLE A - jif r�-1' � y No. 42101/3 ORA ESSELTE 1 Q% s ® b o I n Sherman Inspection, Inc. Inspecting The American Dream No.Attleboro, MA 02763 Phone 1-508-320-2296 www.shermaninspection.com shermaninspectiongverizon.net Dear Tom McKean This letter is to explain,why the septic system at 6 horatio In,in Centerville,ma was.failed on 03/18/2010 and then again passed on 05/02/2010.Please see all attached photos and documents. On 03/18/2010 Sherman Inspection,Inc.performed a title 5 inspection at property located at 6 horatio In in Centerville,ma.At that time,I had found,rags and other debris, stuffed into the inlet baffles and the outlet baffles of the septic tank,the d-box showed rags that must have made it through the pipe system. The cast iron pipe under the crawl space was cracked,and there was leakage onto the ground surface. The 2 leach chambers were found to be free of any obstructions at that time.All man hole covers, including the d-box covers were opened and inspected.At this point,I failed the system,and recommended that the system be cleaned out,as well as the d-box be cleaned out,and the cast iron pipe fixed.The pumper was scheduled,the.system,was cleaned and dosed,and the pipe was replaced with PVC drainage pipe. On 05/02/2010 Sherman Inspection,Inc.performed a re-inspection of the above named system,after all was repaired, and cleaned and dosed out.All man hole covers were re-opened,as was the d-box,and inspected for any problems,none were found.At that time, I had entered the crawl area,and inspected the DWV system in question,and found all to be replaced and in good working order.At this time,the manhole covers and the d-box cover were left open,as I introduced large volumes of water,to see if the system was actually performing to specifications,and I had found no problems at all with this system at that time of inspection,so a new report was submitted as a passed system.Please see all attached documents and photos. Steven Sherman W E Sherman Inspection,Inc. www.shermaninspection.com 508-320-2296 CeX-) rn Steven Sherman Sherman. spection Inc.:. v r i Parvin, Lindsay From: Parvin, Lindsay Sent: Friday, May 21, 2010 3:00 PM To: 'shermaninspection@verizon.net' Subject: 6 Horatio Lane Mr. Sherman, Please be aware that the letter you sent regarding 6 Horatio Lane does not contain any attached photos and documents as indicated. Feel free to email any photos or documents to this email address and I'll be sure Mr. McKean receives them. Thank you. Lindsay Parvin Health Division Assistant (508)862-4644 lindsay.parvin@town.barnstable.ma.us Town of Barnstable 200 Main Street Hyannis, MA 02601 1 r � Page 1 of 1 Steven Sherman From: "Parvin, Lindsay" <Lindsay.Parvin@town.barnstable.ma.us> Date: Monday, May 24, 2010 11:11 AM To: "Steven Sherman"<sshermanll@verizon.net> Subject: RE: 6 Horatio Lane Mr Sherman, My system does not allow me to open this file type. Maybe printing out a hard copy of the pictures and mailing them or cutting and pasting into a word file would be the best way. Thanks. Lindsay Parvin Health Division Assistant (508) 862-4644 lindsay.parvin .town.barnstable.ma.us Town of Barnstable 200 Main Street Hyannis, MA 02601 -----Original Message----- From: Steven Sherman [mailto:sshermanll@verizon.net] Sent: Saturday, May 22, 2010 10:49 AM To: Parvin, Lindsay Subject: Re: 6 Horatio Lane More photos of 6 horatio lane. Steve From: Parvin, Lindsay Sent: Friday, May 21, 2010 3:00 PM To: shermaninspection@verizon.net Subject: 6 Horatio Lane Mr. Sherman, Please be aware that the letter you sent regarding 6 Horatio Lane does not contain any attached photos and documents as indicated. Feel free to email any photos or documents to this email address and I'll be sure Mr. McKean receives them. Thank you. Lindsay Parvin Health Division Assistant (508)862-4644 lindsay.parvin(&town.barnstable.ma.us Town of Barnstable 200 Main Street Hyannis, MA 02601 5/24/2010 r Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every Centerville MA 02362 05/02/2010 page. Citylrown 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. ImporWit7,f wgen A. General Information filling Qut,fortn�,_. �. on the compuUery key toaaaove yai�r 1 use rmohe tab 1. in r Spector: -1 cursor.-.,do not Steven Sherman use tf retu"" Name of Inspector 3 key. Z-m. Cw Sherman Inspection, Inc. Company Name 97 Stanley Street Company Address N. Attleboro, MA 02763 F City/Town State Zip Code 508-320-2296 S14126 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The sy ® Passe Conditionally Passes ❑ Fails ❑ N eds Fu er Eval tion b he Local Appr ving Authority 05/02/2010 1 or' 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 4 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 off.icial Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form: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 M s 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 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 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every Centerville MA 02362 05/02/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 IfN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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 CM 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of.bedrooms): 330 t5ins•09/08 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 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. City/Town State Zip Code Date of Inspection D. System Information Description: System is a concrete septic tank 1500 gallon, with a concrete d-box and 2/500 gallon leaching chambers. Tank was found to be cleaned, baffles and tank werein good condition,both the inlet tee and outlet tees were clean and in good condition. Number of current residents: vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No j Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): N/A Detail: No water meter readings were supplied by bank, this is a bank owned property, and at time of inspection, no records were produced or supplied. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A No records at BOH and no records supplied by owners or bank. Was system pumped as part of the inspection? ® Yes ® No If yes, volume pumped: Unknown gallons How was quantity pumped determined? Was Not Reason for pumping: To Re-inspect tank and system for any failures. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 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 �M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 06/07/1996 Information from BOH and permit on file. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is fed by 2 locations, (duplex property). New PVC Piping was installed on drain lines, and all function well at this time. All components, were re-inspected for any problems, and, no problems were found. Septic Tank(locate on site plan): 1' 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: 1500 gallon Sludge depth: 0" t5ins•09/08 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 M < 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityrrown 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 0" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" 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.): System is a concrete septic tank 1500 gallon, with a concrete d-box and 2-500 gallon leaching chambers. System has been recently pumped out, and all DWV lines replaced.All appears to be in good working order. 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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 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 4 M , 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): d- Box was found to be level, cleaned, and working well at time of inspection. 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: SAS was located and inspected, no problems found at that time. SAS consists of 2-500 gallon leaching chambers. soil around system was dry, and no unusual vegitation observed. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: i 2-500allon ® 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.): SAS consists of 2-500 gallon leaching chambers. soil around system was dry, and no unusual vegitation observed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts ti Title 5 Official Inspection .Form SubsurfRC&Sewage Disposal Syshm Form-Not for YolursW Assessments 6 Horatio Ln Properly Address One West Bank Owner owners Name information is t�ri�BLVllte MA 02362 03/1=010 required for every t'�t/TcnVi SZa Zip Code Dame of U vVeCUM page- o. System Information (cunt) Sketch Of Sewage Disposal SYSWM Provide a view of the sewage disposal system.Including ties to at least two periment reference landmarks or benchmarks,Locate all wells within 100 feet. Locate where public water supplY enters the building.check one of the bones below: ® hand-sketch in the area below ❑ drawing attached separatelY Rza,?, gLI%AR" 110� 0- �3 5 y�to Tdies ewhapeCOMFOWSUbPjffW8SeWW Dbpod SpgtgM.pap 15017 LSars Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8 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: 1996 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: talked with health agent to determine high ground water. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Talked with BOH agent about area ground water, walked the neighborhood and abbutting properties. Used a ground augar to take samples of soil to a depth of 6' looking for water to perk up. used a steel rod around the SAS to see if water was to perk up. 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 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 05/02/2010 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 i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 0 allo: / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BAR NSTABLE., MASSACHUSETTS 0[pplic tion for Dis ppoml *pgtem Construction Vermit Application is hereby made for a Permit to Construct( )or Repair(V5an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Z60jV,2,(,Z 'PiNe, 6/` g)e1,- '®n ce-/1 W Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1911`V40,-641 T: Type of Building: Dwelling No.of Bedrooms Garbage Grinder(14W Other Type of Building OUjll&k No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //e gallons per day. Calculated daily flow 3,30 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable)' d 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 Certifi- cate of Compliance has been issued y th' ar Heal Signed A Date Application Approved by lea IF Application Disapproved for the following reasons Permit No. Date Issued 0. THE COMMONWEALTH OF MASSACHUSETTS { PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprtcatton for Dtgpool *p5tem Con5tructton permit Application is hereby made for a Permit to Construct( )or Repair(V5"an On-site Sewage Disposal Sjsdel a£= M, Location Address or Lot No. Owner's Name,Address and Tel'"No. 26D 26 Z AW Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t�of�Go�i' C®r�6y: Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( � Other Type of Building , k No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //,tl gallons per day. Calculated daily flow gallons. ` Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when appl'cable) X�,S 011 -1 'e'l—"I&w t7 O/1 l! z?O /4Ll v 0 O 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 Certifi- cate of Compliance has been issued y th. ard< f Heal Signed r Date 115 Application Approved by Application Disapproved for the following reasons'_- `-- j Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS z gL l e/ PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-s' �')on e Sewage Disposal System installed( )or repaired/replaced( by / 7'D�D / L �/!57` for as Z , ,,/-2-,6Z x57l he .S CG`1 71e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. V q dated Use of this system is conditioned on compliance with the provisions set forth below'-' `� T No. -4K 7 9 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �tg�lOgaY �ipgterrY �J OngtrUction �erltYtt Permission is hereby gran ted° /'�`Gl C<el to construct( )repair(✓)an On-site Sewage System located at 7 ALAvl f S� and as described in the above Application for Disposal System Construction Permit. The applicant recogniz his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must b com leted/within two years of the date below. i O f Q Date: (n Approved by o a { t _57 /41 � w � 1 o r� to 74 C4 Q CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'TItWHON PERNII"I'(WIT1110UT DESIGNED PLANS) 1, jert hereby certify that the application for disposal works construction permit signed by me dated �S`/�� , concerning the property located at ZZO I-. 12 meets all of the following criteria: ✓ There arc no wcllands within 300 feet of the proposed septic system Y T ,cre arc no private wells within 150 feet ofthe proposed septic system observed ground«ater table is 14 feet or greater below the bottom ot`the leaching facility • There is no Increase in flow and/or change In use proposed k/ There are no variances requested or needed. SIGNED : f DATE: /S—1 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER iAUach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan, this plan should be submitted). L' t,;` `` '' ^�s;�. Lfi,^vfif+'?fiy, 4. r�').r .�,tF<:'^ ;v-''�k s`�"-� t',ia'i "4 r�'V. ✓r 9 i f:?� Yt'w..} �12+t �'".f ..'e: � v C_:` Lsx °' 7� � a545� ,� Ss sS' �'"'. .°t u4� ::xs .��. I Town of Barnstable Barnstable 4v ti A"maicacRy aaatvs'enst.�, Regulatory Services Department * i639- ♦ Public Health Division m ArFD"i1P�a 200 Main Street, Hyannis MA 02601 2 , Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009281 3/24/2010 Raineria Laftsidis 1888 E. Walnut Street Pasadena, CA 91101 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 6 Horatio Lane Centerville,MA was last inspected on March 18, 2010, by Steven Sherman,. a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. • Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. =ocF THEB :ARD OF HEALTH.n, R. ., LLr.I p Agent of the Board of Health Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown , State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information (�I on the computer, use only the tab 1. Inspector: key to move your cursor-do not Steven Sherman use the return Name of Inspector key. Sherman Inspection, Inc. Company Name 97 Stanley Street Company Address Im N. Attleboro, MA 02763 F Cityrrown State Zip Code 508-320-2296 S14126 Telephone Number License Number B. Certification . I certify that I have personally inspected the s age disposal system at this address and that the information reported below is true, accurate d complete as of the time of the inspection. The inspection was performed based on my/training and a erience in the proper function and maintenance of on site sewage disposals stemsf am a DEP ap oved system inspector pursuant to Section 15.340 of Title 5(310 C R 15. 0 ).The system: UJt Ur, 00 E:a ❑ passes ❑ Conditionally Passes ® Fails 7 r I Need urt r Evaluaf n the Local Approving uthority s Nco e AA 03/18/2010 s�pe. is Sign t re Date nj 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. L ' (3110 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Se4 Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 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: ❑ 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: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09108 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 M ,•�''� 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form: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 wM 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every Centerville MA 02362 03/18/2010 page. Citylrown 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 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 Y day flow t5ins-09/08 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 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This asses system if the well water analysis, performed y p y , p ed 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. t5ins•09/08 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 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is centerville MA 02362 03/18/2010 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. City/Town State Zip Code Date of Inspection D. System Information Description: System is a concrete septic tank 1500 gallon, with a concrete d-box and 2 500 gallon leaching chambers. Tank was found to be abused by ocupants, baffles and tank were full with rags, wipes, condoms, and all sorts of debris which has floated to the top, and clogged the tanks usefullness. Effluent has backed up to house, and yard. Both the inlet tee and outlet tee were clogged with rags and debris, as was the d-box. Number of current residents: vacant 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A 9 ( Y 9 (gP ))� Detail: No water meter readings were supplied by bank, this is a bank owned property, and at time of inspection, no records were produced or supplied. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commerciallindustrial 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M z 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A No records at BOH and no records supplied by owners or bank. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 06/07/1996 Information from BOH and permit on file. Were sewage odors detected when arriving at the site? ® Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): System is fed by 2 locations, (duplex property). both cast iron lines and t-y connectors are on grade or partialy below. both cast iron sections have vertical seam cracks, and are wet, and show signs of leakage to ground below. Both should be replaced. Septic Tank(locate on site plan): ' Depth below grade: 1 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: 1500 gallon Sludge depth: 2' plus t5ins-09/08 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 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. CityrFown 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 0" 1. Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" 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.): System is a concrete septic tank 1500 gallon, with a concrete d- box and 2-500 gallon leaching chambers. Tank was found to be abused by ocupants, baffles and tank were full with rags, wipes, condoms, and all sorts of debris which has floated to the top, and clogged the tanks usefullness. Effluent has backed up to house, and yard. Both the inlet tee and outlet tee were clogged with rags and debris, as was the d- box. Recommend, that system be pumped, both at tank, and d-box and chambers, and then re-inspected to validate it's integrity. 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 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owners Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade. Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of.Massachusetts TRW 5 Official 0nspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D- box has sewrage carry over into box, solids carry over observed. it was obvious, that debris from tank, have made there way to the d-box and clogged the system. It is recommended, that the system be cleaned, and then dosed with water, and then re- inspected for compliance with 310 CMR 15.303 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.): 1 1 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: SAS was located and inspected, no problems found at that time. SAS consists of 2-500 gallon leaching chambers. soil around system was dry, and no unusual vegitation observed. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ 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.): SAS consists of 2-500 gallon leaching chambers. soil around system was dry, and no unusual vegitation observed. 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 Lt5in. 09/08 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 M s 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection :Form subsurfm Sewage Dftposat sin Form-Not for Vaunbuy Assessrrterft 6 Horatio Ln Property Address ono WGt Bank Owner Owner's Name information is MA 02362 03118r2010 required for every O ft Page- �R� Sid � e Zo Code e of Inspection Page- D. System Information (coat) Sketch Of Sewage Disposal System.Provide a view of the sewage disposal system,including ties to at least two perrrmerit 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 st 5 y� __M-ti Ti9e501faa�t+spe�anFam�Shoe � -Page ISO tt t�-09R)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every centerville MA 02362 03/18/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8 feetfeet I 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: 1996 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: talked with health agent to determine high ground water. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Talked with BOH agent about area ground water, walked the neighborhood and abbutting properties. Used a ground augar to take samples of soil to a depth of 6' looking for water to perk up. used a steel rod around the SAS to see if water was to perk up. Before filing this Inspection Report, please see Report Completeness Checklist on next page. L,5,nr, 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 6 Horatio Ln Property Address One West Bank Owner Owner's Name information is required for every Centerville MA 02362 03/18/2010 page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 CERTIFICATION OF SKETCII AND APPLICATION FOR A DISPOSAL WORKS CONS-1'RUC'TION PL;Rt1n"(wi-i'llt•)U'I'DESIGNED PLAN51 Xa/ 9/©//,/hereby certify that the application for disposal works 1 -- e4 con�n8 the construction permit signed by me dated 5 pro ert located at Z64 Z 62 p/�� �` meets all of the p Y following criteria: ✓ There are no wetlands within 300 tcet of the proposed septic system �7Th cre are no private«"oils within 150 rect of the proposed septic system obsefTed groundix:ster inbte is 14 feet or greater below the bottom of the leaching facility • There is no increase in now and/or change in use proposed i✓There are no variances requested or needed. SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAlinch n sketch plan of the proposed system.Also if the licensed Installer posesses a cettHted plot plan. this plan should be submittodl. `. > '.(� ' _. ,t.`➢5 �. M1.rk �}g,.tF' n..tr�'. # �a'.w•.,....a' � `' avz�o`''°sr rY � , �. � �2 �, ��.� � A� � o o � �. �� J � � � w j J � 0 � � � �� � � � � ��� �� «��� . � � �,�� - � �- �� l�f ^'�--. s� � �i� �. �. 4 �. �, No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS 0(ppCication for 3i9pogal 6pgtem conaruction Permit Application is hereby made for a Permit to Construct( )or Repair /�an On-site Sewage Disposal System at: / / /j,� Owner's Name.Address and Tel.No. PZ ress or I.a No. (/�_ /(j��"`N1MJ P!Pi 5®h �z �i�e slir�me.Address.and TeL No. [ksigier's Name.Address and TeL No.ra�vsf yy No137`��s,�r://s Type of Building: { Dwelling No.of Bedrooms ?J Garbage Grinder(�� Other Type of Building l! No.of Persons Showers( Cafeteria( ) Other Fixtures jI Ions per day. Calculated daily flow 3�® gallons. Design Flow � P y Revision Date � Plan Date Number of sheets Title Description of Soil i :�ys Nature of Repairs or Alterations(Answer when applicable 7,� O' j i Date last inspected: i 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 Certifi- cate of Compliance has been issued y th' Heal Date Signed } Application Approved by Application Disapproved for the following reasons i i Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS i Certificate Of Compliance / i THIS IS TO CERTIFY,that the On-s a Sewage Disposal System installed( )or repaired/replaced(ate on by ,AO/ULOAI L. G'/1 r` for as Z(/J 4 Z,i 1 P%he- S Z C e e fiP /�� � - has been constructed in accordance + =;f with the provisions of Title 5 and the for Disposal System Construction Pett No. Le �— Use of this system is conditioned on compliance with the provisions set forth below: ---- -- --- 7 $Z F y� --- No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30igpogai 6pgtem Con/gtruction 3permit Permission is hereby granted)o to construct( )repair(, 1 an On-site Sewage System located at C 2r/ and as described in the above Application for Disposal System Construction Permit.The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. JJ Q All construction must co 'le within'two years of the date below. PH APPro ed b f v y Date: �`.. Y � J ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRSvm- . DEPARTMENT OF ENVIRONMENTAL PROTECTION JAN 2 7 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (o+,bl'c-tO -A<A Property Address: 2 6 0/2 6 2 P i n t R t rent-t-ruill.e SA% Owner's Name: ,-i „n WQ loll ar [SAP Owner's Address: 29RI?in[=el —P — PARCI;I! � Date of Inspection: a ®T '--'^- Name of Inspector:(please print) Wi 11 i am E_ •Robinson sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 5081 775-8776 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.1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: P/asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Si&ature: �, �,j, �/� 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 approxing 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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 6 0/2 6 2 Pine St Centerville Owner: Lorin Wordell Jr Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. �Syvstcm Conditionally Passes: O`ne 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 tankiis 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: Obs rvation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval f Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The s tem required pumping more than 4 times a year due to broken or obstruxied pipe(s).The system will pass inspectio if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 4,. ND explain: I Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 260/262 Pine Street Centerville Owner: Loring Wordell Jr Date of Inspection:_ �� ✓U "� C. Furthe Evaluation is Required by the Board of Health: Condit ons exist which require further evaluation b the Board of Health in order t Y o 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 istt 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functi Ining 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 watci 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 front a private water supply well- Method used to determine distance "This sys cm 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 prese ce 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: 3 Page 4 of I I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 260/262 Pine Street � �rt�ervil=fie Owner: Jr Date of Inspection: D. S.•stem Failure Criteria applicable to all systems: You m st indicate"yes"or"no"to each of the following for all inspections: Yes N, Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or.available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number IlAny of times pumped _ portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private uatu supply well with no acceptable water quality analysis.IThis 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 forma (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. E. arge Systems: To b considered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000 gpd• You m Ist indicate either"yes"or"no"to each of the following: (The fol owing criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well if you hav answered"yes"to any question in Sectian E Litero e system is csidered a significant threat,or answered "yes"in Secrtion D above the large system has failed.The cmmcr or operator of arry 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�)Istem owner should contact the appropriate regional office of the Department. vr� 4 IPage5ofII I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ 260/262 Pine Street Centerville Owner: T.nri nr� Wordell Jr Date of Inspection: 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 tJ/Were any of the system components pumped out in the previous two weeks? iZ — Has the system received normal flows in the previous two week period? zmave 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? V _ 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: 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.0 is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 I � i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 260/262 Pine Street Centerville Owner: Loring WordelT Jr Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 Number of current residents: w Does residence have a garbage der(yes or no): Is laundry on a separate sewage system(yes or no):,A:�C[if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if ava able(last 2 years usage(gpd)): 2002 28,000 gals Sump pump(yes or no):J/0 2003 43,000 �— Last date of occupancy: 3�d gals � l COMM CIAL/INDUSTRIAL Type of es blishment: Design flo (based on 310 CMR 15.203): gpd Basis of de ign flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial aste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met r readings,if available: Last date f occupancy/use: OTHER describe): GENERAL INFORMATION Pumping Records Source of information: i Was system pumped as part of the inspection(yes or no): D If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP 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) _Tight tank —Attach a copy of the DEP approval _Other(describe): Approximate age of all components, ate installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):yL U 6 • Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260/262 Pine Street Centerville— Owner: Loring Wor e 1 Jr Date or Inspection: BUILD G SEWER(locate on site plan) Depth belo grade: Materials f construction:_cast iron _40 PVC_other(explain): Distance fir inprivate water supply well or suction line: Comments(on condition ofjoutts,venting,evidence of leakage,etc.): SEPTIC TANK: /(locate on siteplan) 1 Depth below grade: Material of construction:—�Eoncrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):—(attach a copy of certificate) , I ) b Dimensions: �„ `N. t, 4:r 1(� Sludge depth: IL- " Distance from top of sludge to bottom of outlet tee or baffle: r 1 Scum thickness: _(I— �� 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ZD 1 ' How were dimensions determined:_ O j z"- Cd u LT5-� 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 RAP:_(locate on site plan) Depth belo grade:_ Material of c nstruction:_concrete metal fiberglass_polyethylene other (explain): — Dimensions: Scum thickn ss: Distance frob top of scum.10 top of outlet tee or baffle: Distance fr m bottom of scum to bottom of outlet tee or baffle: Date of Iasi pumping: Comment (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related ,o outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260/262 Pine Street Centerville Owner: T-or ;ng Wordell Jr Date of laspection:_ l"� - ©A—/ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth be) w grade: Material o,construction: concrete metal fiberglass_polyethylene other(explain). Dimension : Capacity: gallons Design Flaw: gallons/day Alarm present(yes or no): Alarm lev�stl: Alarm in working order(yes or no): Date of I pumping: Comme s(condition of alarm and float switches,etc.): DISTRIBUTION BOX: `�(if resent must be o ened locate on site Ian P P )( 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: (locate on site plan) Pumps in working order(yes or no): Alarms in working orde (yes or no): Comments(note eonditi n of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260/262 Pine Street Centerville Owner: Loring Wordell Jr Date of Inspection: i �3-0 SOIL ABSORPTION SYSTEM(SAS): ✓(locate on site plan,ezcavation'not required) If SAS not located explain why: Type .. aching pits,number:_ eaching 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�f vegetation, etc.): CESSP S: (cesspool must be pumped as part of inspection)(locate on site plan) Number and onftguration: Depth—top o liquid to inlet invert: Depth of solid}-layer: Depth of scum ayer. Dimensions of esspool: Materials of co struction: Indication of groundwater inflow(yes or no): Comments(notf condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimension Depth of solids: m Coments( lote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260 f .6 Pint- Street n rvi11P Owner: T.nri nglprdell Jr Date of Inspection: —t� 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. �y �3 10 Pige 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260/262 Pine Street CentervtTle Owner: Loring wordel.1 Jr Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: 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: 11 Page 10 of 12 V o Q OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION(continued) Property Address: Date of Inspection. Jc�"�QGt SKETCH OF SEWAGE DISPOSAL SYSTEM Lh 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. Gv a� .� 3S 5 in P`Dp 1NE rDh�o Town of Barnstable �p"fs pft, Public Health Division p E' BARNSfARLE. MASS. 200 Main Street '' 679 P�� Z tm-AWTNEY BOWES FD MPy Hyannis,MA 02601 ' $R n5 �p 0004606238 SO 60 0 7008 1830 0002 0500 9281 ' MAILED FROM ZIP CODE 02601 RETURN RECENT REQUESTED ., d Raineria Laftsidis 1888 E. Walnut Street Pasadena, C�_aa ABC SUCH NUMBER UNABLE TO FOPWARD r_'540alikka$6 { SECTIONCOMPLETE THIS ON DELIVERY SENDER: COMPLETE THIS SECTION \ — I ■ Complete items 1 2,and 3.Also complete A. Signature ❑Agent item 4 if Restricted Delivery is desired. X ❑Addressee ■ Print your name and address on the reverse so that we Can return the Card to you. B. Received by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, I or on the front if space permits. D. Is delivery address different from item 1? ❑Yes I 1.Article Addressed to: If YES,enter delivery address below: ❑ No ink I ri Q LQ�k G�S I �- 3. Service Type ❑Certified Mail ❑Express Mail -: � ❑Registered ❑ Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. I I 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number 1 7008 1830 0002 0500 9281 \ / I (Transfer from service label) \ .Ps Form 3811,February 2004 Domestic Return Receipt to25s5 0�2 tv��sao I \ > J i� �yoFINKE r�ti Town of Barnstable Barnstable Regulatory Services Department AS-AmedtaC ft MASS. Public Health Division i639• �� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009281 3/24/2010 Raineria Laftsidis 1888 E. Walnut Street Pasadena, CA 91101 ORDER TO COMPLY..WITH STATE ENVIRONMENTAL CODE, TITLE 5 The.,septic,system located at_6 Horatio Lane Centerville,MA was last inspected on March 18 2010, by Steven Sherman;: a certified septic inspector for the State of Massachusetts.., The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310.CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. • Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within'the dead]ine'period will result`inl{future ,enforcement action. 1T 1P, .r F THE B ARD-OF HEALTH A ,r .i t...... / • J.• }�. �J \ .F. Y F .i rt-',L'�1.1 4�L: ��1ST t.I•JG (h J� f .t.» ♦.� J • �IS i, I70 C ean,�R. ., �� e� �{ �. ;F T! C , Agent of the Board of Health