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HomeMy WebLinkAbout0180 HORSESHOE LANE - Health 180 HORSESHOE LANE Centerville A = 207 — 131 N Sivii E A � No. H1630R UPC 10259 smead.com • Made in USA 2J �2a m S J J_ c v n c � s �J I n. e gums I (�O. Ks Q- La n c 5 Commonwealth of Massachusetts Title 5-Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 Cityrrown State ZipCode Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 3f 1Z32-71 (� 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 CitylTown State 508.272.6433 Zip Code i Telephone Number i l B. Certification i 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails k I ❑ Needs Further Evaluation by the Local Approving Authority Inspec ignatu 5/26/17Date 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 LO 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 m at that time.This inspection does not address how the system will perform in the future under ,r--the same or different conditions of use. 180 Horseshoe Ln•03/08 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 j t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 cityffo 1 State 5/26/17 Zip Code Date of Inspection B. Certification (coat.) 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 i indicated below. Comments: f *****Per BOH agent Thomas McKean the system is considered a"Pass"for the purpose of title transfer only. I B) System Conditionally Passes: f� I I 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 efittration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as i 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: 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): ❑ broken pipe(s)are replaced i i I ❑ obstruction is removed I 180 Horseshoe Ln•03= Title 5 Offiaal Inspection Forth:Subsurface sewage Disposal System•Page of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville Ci frown MA 02632 State Zip C— otl 5/26/17 Date of Inspection �. Certifitc�ti®n (cont.) . B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a 6 I ❑ The system required pumping more than 4 times a year due to broken system will pass inspection if(with approval of the Board of Health) or obstructed pipe(s)_The ❑ broken Pipe(s)are replaced ❑ obstruction is removed ND Explain: E n/a r 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 I 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 r i 2. System will fail unless the Board of Health(and Public Water Supplier,if any) r determines that the system is functioning in a manner that protects the public health, safety and environment: I ❑ The system has aseptic 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 I supply. f ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 180 Horseshoe Ln•o=8 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts -- Title 5 Official Inspection _ Subsurface Sewage Disposal System F �®r Not for Voluntary Assessments 180 Horseshoe Ln- Property Address Brescia Owner's Name Centerville City frown MA 02632 5/26/17 State ZIP 6;d Date of Inspection �. Certificafion (cont.) C) Further Evaluation is Required by the Board of Health(cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'"` Method used to determine distance: "*This system passes if the well water �I bacteria indicates absent and the Presence ammonia nitrogenperformed at a D nd n tate n troEP certified genOS'for coliform less than 5 a g equal to or bps provided that no other failure criteria are triggered.A co of the analysis must be attached to this form. 3. Other. n/a 4 i f D) System Failure Criteria Applicable to All Systems: F ! You must indicate"Yes"or"No"to each of the following for all inspections: i Yes No I i ® Backup of sewage into facility or system component due to overl I clogged SAS or cesspool oaded or ® Discharge or ponding of effluent to the surface of the ground or surface waters I 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 I than Yz 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. 180 Harsestwe Ln•03I08 i Title 5 Official Inspection Form;Subsurface Sewage Disposal System.Page 4 of 15 t COMMonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville Cityrrown MA 02632 State 5/26117 Zip Code Date of Inspection B. Certification (Cont.) D) System Failure Criteria Applicable to All Systems(cont): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This System passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 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.] ❑ M 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 i 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. l i Yes No I ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ; the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ ❑ Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate regional office of the Department. 180 Horseshoe In•03108 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 t Comm onwe-- alth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 180 Horseshoe Ln. Property Address Brescia Owners Name Centerville MA Citylrown 02632 5/26/17 State Zip'CodeDate of Inspection C. Checklis# Check if the following have been done_ You must indicate"yes"or"no"as to each of the following: 4 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? i❑ ® 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) i ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? i[® ❑ Were all system components, excluding the SAS, located on site? t ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank j 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 I information on the proper maintenance of subsurface sewage disposal systems? i The size and location of the Soil Absorption System(SAS)on the site has t 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)] i ISO Horseshoe Ln•03MB Title 5 Official Inspection Form:Subsurface Se4%age Disposal System Page 6 of 15 I e i Corr Motnwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address + Brescia Owner's Name Centerville MA 02632 City/Town State 5/26/17 Zip Code Date of Inspection D. System Information I Residential Flow Conditions: I Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330._ I Number of current residents: 2 Does residence have a garbage grinder? i ❑ Yes ® No i f Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No s Laundry system inspected? ❑ Yes ® No Seasonaluse? I ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)).- Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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? i ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Na 180 Horseshoe Ln-03108 Tdfe 5 Official Inspection Fomc:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts- - t Title 5 Official Inspection For f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 180 Horseshoe Ln. Property Address { Brescia Owners Name 1 Centerville MA cityrrown 02632 5/26/17 State Zp dCoe Date of inspection I i ®. System Infi®rmati®n—(cont.) ; General Information Pumping Records: { Source of information: Pumped 1 r a o er owner i Was system pumped as part of the inspection? r ❑ Yes ® No t If yes,volume pumped: r gallons How was quantity pumped determined? Reason for pumping: "Type of System: 1 1 Septic tank, distribution box, soil absorption tIo n system rP ten I ❑ Single cesspool I i ❑ Overflow cesspool ❑ Privy i f ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) I ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest 1 inspection of the I/A system by system operator under contract l ❑ Tight tank.Attach a copy,of the DEP approval ® Other(describe): x Approximate age of all components,date installed(if known)and source of information: 1995 per BON record Were sewage odors detected when arriving at the site?" El Yes ® No e 180 Horseshoe Ln-03/QS Tide 5 Official Inspection Form Subsurface sewage oisposal system-Page a of 15_ i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville Cityrrown 5/26117 St 02632 ate zip Code Qate of Inspection D. System Information (cont.) Building Sewer(locate on site plan): I Depth below grade: 2' feet Material of construction: cast iron ❑40 PVC ❑other(explain): I Distance from private water supply well or suction line: >10' i feet t Comments(on condition of joints, venting,evidence of leakage, etc.): 4 Septic Tank(locate on site plan): 1 Depth below grade: 20" feet Material of construction: ®concrete ❑metal ❑fiberglass 9 El 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: 1000g Sludge depth: trace-1" i Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle '2 Distance from bottom of scum to bottom of outlet tee or baffle '2 How were dimensions determined? Measured i 180 Horseshoe Ln•03f08- t Title 5 Official tnspection Form;Subsurface Sewage Disposal System•page 9 of 15 f t t I Commonwealth of Massachusetts - .- Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 cityrrown 5/26/17 State Zip Code Date of Inspection De System Information (coat.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pumping suggested every 3 yrs to prolong the life of the system t i Grease Trap(locate on site plan): " Depth below grade: feet Material of construction: " ❑concrete ❑metal ❑fiberglass 9 ❑ polyethylene El other(explain): " n/a Dimensions: tt Scum thickness I Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle {I 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.): I n/a I I i c Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): t Depth below grade: Material of construction: j ❑concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): n/a ! 180 Horseshoe Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 ' " t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments ' 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) I Tight or Holding Tank(cont.) F Dimensions: i Capacity: gallons Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date I Comments(condition of alarm and float switches,etc.): I n/a f; •Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 011 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 2'below grade, no adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 180 Horseshoe Ln•03108 Tile 5 Official Inspection Form:Subsurface Stwage Diisposa!S ystem•Page 11 of IS Commonwealth of Massachusetts -- - Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 t Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): n/a 1 Soil Absorption System(SAS)(locate on site plan, excavation not required): " If SAS not located,explain why: j Type: { ® leaching pits number: 1 i ❑ leaching chambers number. ❑ leaching galleries number f ❑ 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.): Leach pit has 18"of effluent at this time,sidewalls are clean above current level, bottom of pit is 7'6" ; below grade, cover 2'below grade r 180 Horsestme Ln•03IUa Title 5 Official Inspection Form:Subsurface S e Disp osal posal system•Page 12 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26117 City/Town State Zip Code Date of Inspection i D. System Information (cunt.) 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 1 Depth of scum layer Dimensions of cesspool i Materials of construction i t Indication of groundwater inflow ❑ Yes ❑ No t Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, i etc.): t F Privy(locate on site plan): Materials of construction: I Dimensions i Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a ' I } 180 Horseshoe Ln•03108 Title 5 Official Inspection Faun:Subsurface Sewage Disposal System•Page 13 of 15 r t N Commonwealth of Massachusetts -_ _ Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5126/17 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties E to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. COE:D 41. E t 180 horseshoe Ln•OW8 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address R Brescia Owner's Name Centerville MA 02632 5/26/17 Cityrrown State Zip Code Date of Inspection D. System Information (coot_) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells l Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: �f ❑ Obtained from system design plans on record l 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: Augered hole at time of inspection found ground water at 10'6" i t i i Y 180 Horseshoe In•mm Title 5 official Uis pection Form:Subsurface Sewage Disposal System•Page I5 of 15 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A$ 32B Name of Owner PATRICIA AND DAVID MASSICOTT CQ—alccura „Address of Owner: 33 HEMLOCK RD.CARLISLE MA.01741 Date of Inspection: 9/20/99 Name of Inspector:(Please Print)JOHN GRACII am a DEP approved system inspector pursuant to Section 15.340 of Tdle 5(310 CMR 15.000) ►�lac.Company Name: n/a 0Mailin Address: n/a9 Telephone Number: n/a � yyCERTIFICATION STATEMENTyI certify that I have personally inspected the sewage disposal system at this address and that the information rura e and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further E luation By the Local Approving Authority performing at the time of the inspection.My Inspection does _ Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:9/27199 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)withln thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&328 Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n(a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced n& The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. 4 _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla..(approximation not valid). 3) OTHER nla revised 9/2/98 Page 3 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9120/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n(a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles i or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. r revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20199 FLOW CONDITIONS ' RESIDENTIAL: Design flow:AiQ g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: IV Number of current residents:11 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): n1A Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: Wa gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:Wit Last date of occupancy: WA OTHER: (Describe) Wa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information:' nLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa- gallons Reason for pumping:,.nta TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 5.26.95 PERMIT95.240 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) n[a SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No n& Dimensions: L 8'6"H b'7"W 4'10" Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness:,Q Distance from top of scum to top of outlet tee or baffle:-X Distance from bottom of scum to bottom of outlet tee or baffle: JI& How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n& Dimensions: nLa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:iiLa Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20199 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: Wa Capacity: nta gallons Design flow: n& gallons/day Alarm present: NO Alarm level:jiLa_ Alarm in working order:Yes_No_ NQ Date of previous pumping: nta Comments: (condition of inlet tee,condition of alarm and float switches,etc.) , n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n[a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: B'X4'LEACH PIT leaching chambers,number: _nLa leaching galleries,number: _nLa leaching trenches,number;length: nLa leaching fields,number,dimensions: nta overflow cesspool,number: nLa Alternative system: Wa Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT HAS NOT HAD MORE THAN 4"OF WATER IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: nta Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: nta Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 3° p a � R h �c a� s 2'( o revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 180 HORSESHOE LANE CENTERVILLE MAP 207PAR131L 32A&32B Owner: PATRICIA AND DAVID MASSICOTT Date of Inspection:9/20199 NRCS Report name: n& Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: Wa Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10 FEET revised 9/2/98 Page 11 of 11 g e� ' ASSESSORS MAP N0: No..../_--�-� PARCEL NO: L3 I F�aJ..... .�...C7 Z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AppUratiou for Diirpoottl Worlui Towitrurtion runtit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System � _ q ?J Q fi®rS f �w l� Lorition-Address or Lot No. �,.�(L a o yr ......_.-------•-------------------------- ---------------------------•-•--- .................................... ......... wncr ............................. ......................... -_..._1�L'-?_ ���5 = l_ S� �,�; w res� 'NI�S�n ee Installer Address UType of Building Size Lot............................Sq. feet ►, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv--_.___-___gallons Length---------------- Width--------.------- Diameter... Depth................ x Disposal Trench— No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................._................ Test Pit No. I................minutes per inch Depth of Test Pit_--------------... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ --------------------------------------- --------------------------------•................................................................................... O Description of Soil....... __.. �' , ` - ------------------------------------------•----•-----•••----•-----•---••-•-•----••---- --- ---------------------- -------------------------------------------------------------------------- .....--•---•-------•------- Nature of Repair fterytons— nser when alicable__.____ _..___. ._____qg qe .� l � �o 3.................. ..... --------------- .....o. © ..------ " Agreement: v The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5'of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�beeeen, issued y the board o ealth. C-1 v.X ✓� Signed ........... .. ...(.J� . Application.Approved By ---- --- ..._............ `�'l . - ... e(..:../ .......:.............. 3..77 er N • � Dace Application Disapproved for the following reafonr- -------------------------------------------------------------------------------------------------- ----- ........... ................... .........-----------�--�. p Dace Permit No. .... .. - Issued .. ..^ J Dace m L p�; l7 � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE' Aplifiration for Di-ripn!3al Workii Tomitrurtion ranfit Application is hereby made for a Permit to Construct ( ) or Repair (�j an Individual Sewage Disposal System at: `` .........�m--------• -�......---Q................................................. Locuion-:\ddress J ` or Lot No. r !^1 l(----•--------._..Q:-''�:�^_e -------------------- -- --•-------• - ----f---7-'-'�--------�"-Q�''•�he--e,-------- ............................. o,vncr A�dress YYI Doe mc ...-•--••.--• ..-•-• ................................ `-----•.....__.--------- --•---•OS--------....--..A--~-•--•••-•--- .................... ..................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms------------------------------------------._Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.-..__.__________-____.-_-- Showers ( ) — Cafeteria ( ) � Other fixtures ----=----------------------------------------------------------------- ------------------------ ----- W Design Flow........:...................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width-__..._-__-.__. Diameter_--------------- Depth---------------- x Disposal Trench— No. _-________________ Width___-_-..--___--.--_ Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No................ Diameter_................. Depth below inlet.................... Total leaching area..................sq: ft. Z Other Distribution box ( ) Dosing tank ( ) 0­" Percolation Test Results Performed by--------------------------------------................................... Date---- -------------------------••--••--- a Test Pit No. I................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ (LI Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-_-_-.-----__----- Rr' •---•----•----------•-----•----•--•-.........-•---•-•-••---•---•.............••••••._.-••••---....••......................................................... O Description of Soil........ "__ x -------------------------------------------------- -------------------------------------------------------------- .......... ! CeSS o0 1 U Nature of Repairs,or Alterat'ons—Answer when applicable------ �_��...____..-..���__�______________________�......._.:_____.r-�......__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of"'health. _ Signed ....'..^. _ ...._.......`-`.�''Yl `Qr `"' 'J_.. ...j-.7_7-� l w ce Application Approved By .....Nvti+:--..-.-...- - = - -----. � .. ...�. . Dace Application Disapproved for the following reasons: ....--.--------------------------------------------------------.----------.----------..------- _...............:................................................ ......... ..... ................................................................... '..... .--...... ........... ------------------------ ` t Dace Permit No. - 1: - F. Issued ................3 — 7 .-.-.. ....-_..........-. Uace...................................._. --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C Croft ate of Qlamplinure THGS CIS TO CERTIFY, That the Individual Sewage D)is osal System constructed ( ) or Repaired,,() by -------------(� CL.-`..k--- . .. ....._.._.1....e. ....................: --.-..:. - ---- -- �.� lo,aue� ......... has been installed in accordance with the provisions of TITLE S,a,LTk-Sryate vironmental Code as de5cr_bed in the application for Disposal Works Construction Permit No. -...---.�-.--.--��..........................YY .. dated _--3-.�._.....-.....-..��...-... . .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----_ ------------------------------------------......-.-...--......---- - ._..._. Inspector --- - _.....--..... ... -:... - ............_ - -.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��- a y0 TOWN OF BARNSTABLE No. FEE........................ rr tt1 orkii uai r r#uan ruttt� Permission is hereby granted_.. -_-�•�•---•-••-- ------------- � -.-�ry t •------------------ .----•---------•..... to Construct ( ) o Repair (" an ndividual Sem age Disposal Sy tem at No.. aW -------•-•-------------------•----- -•••--•--•-••....-•-----•--------- . ------ j/ j -Street /J _ (//� ,,,,,as shown on the application for Disposal �t�orks Constructio mtt�No..----___c /,Z�Da e--- -----------�.`...�...._....-- .......................................... --•-••--------------------•••---------------••--------- ... Board of Health DATE....................------------------------------------------------------------ FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS TOWN OF BARNSTABLE e LOCATION 1000 \�Dr SVWC - SEWAGE # VILLAGE reK;feT\l ®k�<-- I\A-,-ASSESSOR'S MAP & LOT O 6 - j a) \ INSTALLER'S NAME & PHONE NOCa f�� t d-rg cjLl L07"®3 +1q SEPTIC TANK CAPACITY 1 0 G ® LEACHING FACILITY:(type) k,1 -y p (size) 1 01bo NO. OF BEDROOMS PRIVATE WELL OR PUBLIC_ WATER BUILDER OR OWNER r\� e_k..c.•r . . DATE PERMIT ISSUED: 9J q DATE COMPLIANCE ISSUED: ` VARIANCE GRANTED: Yes No e � �9 gl, e i x d/ O'•�� Fitle cll�nl_ti Commonwealth of Massachusetts \ Title 5 Official Inspection Form ubsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1 Horseshoe Ln. Pro erty Address Bre cia O f°s Name y terville MA 02632 t��O"m 5/26/17 State Zip Code Date Or Inspection Inspection results must be submitted on this form. Inspection forms way. may not be altered in any . General Information 1. Inspector: Frank Nunes III ame of Inspector as Company Name Box 841 Company Address East Falmouth MA 02536 City/town State 508.272.6433 Zip Code Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site C sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of J Title 5(310 CMR 15.000).The system: COMMG-�� ® Passes ❑ Conditionally Passes ❑ Fails d ❑ Needs Further Evaluation by the Local Approving Authority I 54/1 X 9ff/— i I 5/26/17 ! inspecto s SfgAfure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board I 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. d. 180 Horseshoe Ln•03tt18 Title 5 Offidal 1_ nspec6on Form Subsurface Sevrage Disposal System•Page t of 15 t, 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 City/Town State 5/26/17 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: f 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: C/ '"`*'*Per BOH agent Thomas McKean the system is considered a"Pass"for the purpose of title T[` transfer . atinn of+n„.,n ode 360 n MdUdir j rcni Tres seperation from the bottom of the leachingfacilityto maximum roundwater elevation I B) System Conditionally Passes: I ❑ 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 l approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate L✓ of Compliance indicating that the tank is less than 20 years old is available. N Explain: i ✓'`� 4/ Na lr CF ' 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 180 Horseshoe Ln-OW0.8 - Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 15 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 City/Town 5/26/17 State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): I ❑ distribution box is leveled or replaced ND Explain: n/a l i S I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The I system will pass inspection if(with approval of the Board of Health): { ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a j l� 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 I the system is failing to protect public health, safety or the environment. 1 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 I I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh j I 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 180 Horseshoe Ln•03MB Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 180 Horseshoe Ln. Property Address Brescia Owner s Name Centerville MA 02632 5/26/17 City/Town State ZipCode Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: i This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform i bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or r 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: n/a ! i I D) System Failure Criteria Applicable to All Systems: f I i You must indicate"Yes" or"No"to each of the following for all inspections: Yes No i 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 I than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: i ❑ ® 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. 180 Horseshoe Ln•03l08 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 City/Town state 5/26/17 Zip Code Date of inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrog en 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 t 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. I Yes No '! 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 i ❑ ❑ 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. j 180 Horseshoe Ln•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Flame Centerville MA 02632 Cityrrown 5/26/17 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? i The size and location of the Soil Absorption System(SAS)on the site has I 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)] i i t f 180 Horseshoe t.n-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 City1rown 5/26/17 State Zip Code Date of Inspection- D. System Information Residential Flow Conditions Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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)): Sump pump? ❑ Yes ® No Last date of occupancy: seasonal Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No k Water meter readings, if available: Last date of occupancy/use: Date I 4 Other(describe): n/a I E 180 Horseshoe Ln-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 Cityrrown 5/26/17 State Ylp Code Date of inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 1 yr ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy I ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: 1995 per BOH record f Were sewage odors detected when arriving at the site? ❑ Yes ® No it10 Horseshoe Ln•0308 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20" feet Material of construction: P ®concrete ❑ metal ❑fiberglass 9 ❑ polyethylene ❑other(explain) If tank is metal, list age: years A Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ----------------- ------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: trace-1" I Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness trace-1/2" i Distance from top of scum to top of outlet tee or baffle >2.1 Distance from bottom of scum to bottom of outlet tee or baffle >21, f P How were dimensions determined? Measured 180 Horseshoe Ln•03108 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 180 Horseshoe Ln_ Property Address Brescia Owner's Name Centerville MA 02632 6/26117 Cltyrrown 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.).- Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene El other(explain): n/a 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.): n/a 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 El polyethylene ❑other(explain): i n/a 180 Horseshoe Ln•03/08 I Title 5 Official Inspecflon Forth:Subsurface Sewage Disposal System-Page 10 of 15 I 1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 Cltyfrown State Zip Code Date of Inspection D. System Information (cost.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level, Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): n/a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 01. 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 2' below grade no adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 180 Horseshoe Ln-03108 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 {i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: i { Type: leaching pits number: ❑ 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.): Leach pit has 18"of effluent at this time, sidewalls are clean above current level, bottom of pit is 7'6" below grade, cover 2' below grade 180 Horseshoe Ln•OW08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property Address Brescia Owner's Name Centerville MA 02632 5126/17 Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan): ( p ) Materials of construction: Dimensions Depth of solids Comments(note conditon of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 180 Horseshoe Ln•03108 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln_ Property Address Brescia Owner's Name Centerville MA 02632 5/26/17 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. U v' v CED C- PA C)-v 180 Horseshoe Ln•OWN Title 5 Official Inspection Forth:SubsLdace sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 180 Horseshoe Ln. Property address Brescia Owner's Name Centerville MA 02632 5/26/17 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. 10'6" feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Au ered hole at time of inspection found ground water at 10'6" 180 Horseshoe Ln-03f08 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 15