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Home My WebLink About0105 JAMES OTIS ROAD - Health 105 James Otis Road, Centerville A= 170 - 158 Sl umeatQ® 2J��trWeo�y� llll NoC12543 .. 53LOR HASTINGS. MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 105 James Otis Road — Property Address Gloria Robinson — Owner Owner's Name information is required for Centerville MA 02632 December 8, 2009 — every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information 5001 When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. -- Company Name 189 Cammett Road — Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 _ 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 system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority December 8, 2009 _ In ector's Signatur 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 und'Dr the same or different conditions of use. lD 09-261 Robinson.doc•08/06 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 James Otis Road — Property Address Gloria Robinson — Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. CitylTown 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: Tank is not in need of pumping at this time leaching pit was empty at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ 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 09.261 Robinson,doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road — Property Address Gloria Robinson — Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ 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 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. 09-261 Robinson.doc•08/06 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 w 105 James Otis Road Property Address Gloria Robinson — Owner Owner's Name information is required for Centerville MA 02632 December 8, 2009 - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: — This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool E]r ® Liquid depth in cesspool is less than 6" below invert or available volume is leas than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-261 Robinson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 105 James Otis Road Property Address Gloria Robinson — Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. City/Town State 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.] ❑ ® 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. 09-261 Robinson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 105 James Otis Road — Property Address Gloria Robinson — Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for — every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 09.261 Robinson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road — Property Address Gloria Robinson Owner Owner's Name information is required for Centerville MA 02632 December 8, 2009 - every page. Cityrrown State Zip Code Date of Inspection 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 — 0 Number of current residents: — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Over one year ago. — Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — Last date of occupancy/use: Date Other(describe): 09-261 Robinson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road Property Address Gloria Robinson Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped August 2007 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/18/85 — Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-261 Robinson.doc•08106 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road Property Address Gloria Robinson — Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' _ Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank locate on site Ian): p ( P 16" _ 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 -------------------------------------------------------------------------------------------------- ---------- ----- 8.5' long x 5.2'wide- 1000 gal. Dimensions: 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6 — Distance from bottom of scum to bottom of outlet tee or baffle 12 — How were dimensions determined? Measured _ 09-261 Robinson.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9,)f 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 James Otis Road Property Address Gloria Robinson Owner Owner's Name information is required for Centerville MA 02632 December 8, 2009 every page. City/Town 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.): Tank is not in need of pumping at this time, baffles are intact and clear. Liquid level slightly below outlet invert due to evaporation. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 09.261 Robinson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road Property Address Gloria Robinson Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 11 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.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-261 Robinson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11-)f 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road _ Property Address Gloria Robinson Owner Owner's Name information is required for Centerville MA 02632 December 8, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. — ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: — ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.).- Leaching pit was found empty at time of inspection with a high stain line at 50% capacity. 09-261 Robinson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 cf 15 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 James Otis Road Property Address Gloria Robinson Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. Cityrrown State Zip Code Date of Inspection M 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.): 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.): 09-261 Robinson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I . Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 105 James Otis Road -----------—— —..----—'-- ---------- Property Address Gloria Robinson—___— __---.---------- ------ Owner Owner's Name MA 02632 December 8, 2009 _ information is Centerville ----- required for ---- - --——--- ----._.. --- - -- - CitylTown St-a--te Zip Code Date of Inspection every page. D. System Information (cont.) osal tem including Sketch least Sewage permanent al System: Provide a reference landmarks or Locate h of the sewage 'al.1wells within 100 feet. ties to at least two permane Locate where public water supply enters the building. James Otis Road Water Service / f / l•i,/ r / I ! ! / / \ \ \ 20 / 37 41 0 30 50 w2�, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 105 James Otis Road Property Address Gloria Robinson Owner Owner's Name information is Centerville MA 02632 December 8, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 15+ Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on.record If checked, date of design plan reviewed: 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el 35 and topo map shows property at el. 50. 09-261 Robinson.doc-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 _ TOWN OF BARNSTABLE LOCATION WWAI&E VILLAGE d'-�(1V��Q ASSESSOR'S &PARCEL R46ffAL-LER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) OOG NO.OF BEDROOMS OWNER PERMIT DATE: CO�PrM DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY c 'tltf\ftf4fkJ4J\!\f4ftJtf4i4J4J\f4/\f\/4f\f\f4!\!\?4?\!\f\f4!\J\! \Jv,lt fv,r v,Fv,fv,l v,Jv,Jv,f4i\!\J\r4 4 4 !4 f i f4Jv f\r\!4f\Jt! ! f f f f ! f J f ! ! f r f J ! J f ! J f ! f f J ! f f f r f ! \Ftr\/\r4!\f\Ftf\Fv.J\f4ftF\l4F4f\J4i\ft!\ftr4r\ftf\r\fi rt!\!t!\f 4 4 t 4 \ 4 4 t 4 4 \ t 4 t k t 4 4 \ \ 4 t \ t \ t \ t t 4 \ 4 \ \ \ \ \ \ \ \ \ 4 4 4 4 \ t \ t 4 t 4 4 4 4 4 4 t 4 20 37 ter. 41 �r 0 30 50 un,�� .. c Commonweotth of Mossochusetts Executive Office of Environmental Affairs Department of fir, SF_? 5 1��s Environmental Protection William F.Weld Trudy Coxe Argeo Paul Cellucel 'Daavld B. Struhs U.Governor 6pr � Commiasior>tr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..� �-- . PART A `-Cr� � o CERTIFICATION Property Address: !dv 3/- &IeS OilS 2c.{ Cey.�fj Address of Owner. Date of Inspection: (If different) Name of Inspector. rnp 21.4 Com y Name,Address and Tele hone Number. T VK0/Z / 4) Selo f-i CS CERTIFICATION TIO STATEMEape—k— 3�1v- I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority F ' Inspector's Signature: Date: R'_ 2_77"9•4 The System Inspector shall t a copy of this inspection report to the Approving Authority I within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the mport 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. INSPECTION SUMMARY: Check A, B, C,or D: AJ SYSTEM PASSES: t.� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, 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 yonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)356.1049 a Telephone(617)292-S500 i Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ! Property Address: Owner. Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(&). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 1) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 leas than 5 ppm. S) OTHER (revised 11/03/95) 2 "i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t a s es 4 Qf ft/ Owner. Date of Inspection: V— 2-) D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _, Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is %zthin 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 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: 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 12 of a public water supply well) The owner.or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program s+equuements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: Check if the following have been done: `Pumping information was requested of the owner, occupant,and Board of Health. V ne 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. built plans have been obtained and examined. Note if they are not available with N/A. L�_The facility or dwelling was inspected for signs of sewage back-up. 4t she system does not receive non-sanitary or industrial waste flow 1'he site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. _L'�e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. C/Tie size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _✓The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Design flow: ons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):,&,:::> Laundry connected to system(yes or no):—go!5 Seasonal use(yes or no):& Water new readings, if available: C'O d Last date of occupancy: Q� COMMERCIAL/INDUSTRLAL: Type of establishment: Design now:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes,volume pumped: gallons Reason for pumping: TYPE OF�TEM tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: ��O `� I �1Gr'►'l. Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) S • 1 :T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C ^� SYSTEM INFORMATION (continued) Property Address: O Owner. Date of Inspection: SEPTIC TANK (locate on site plan) 1� Depth below grade:�.D t� Material of construction:_concrete_metal_FRP_other(e:plain) Dimensions: K x Sludge depth:— V Distance from top of sludge to bottom of outlet tee or baine: _ Scum thickness:__ Distance from top of scum to top of outlet tee or baffle:�i� Distance from bottom of scum to bottom of outlet tee or battle:-4e Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,dept of uid level in relatio to outlet invert,structural ' tegrity, evidence of leakaq., e GREASE TRAP'._ (locate on site plan) Depth below grade: Material of construction: _concrete_m FRP--other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or battle. Distance from bottom of scum to bottom of outlet to e: Comments: (recommendation for pumping, tion of inlet and outlet tees o es,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) 6 (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) _/L Property Address: S ��tibe'PS Q 'S �`�v T� Owner. Date of Inspection: TIGHT OR HOLDING TANK_ Gocate on site plan) Depth below glade: Material of construction:_con metal_FRP_other(e=plain) Dimensions: Capacity: Qallons Design flow: gallons/day Alarm level: Comments: (condition of inlet condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level d distnbulion is equal,eviden of solids carry,rmr,avidence of leakage into or out f etc.) PUMP CHAM (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump ndition of pumps and appurtenances,etc.) (revised 11/03/95) 7 • jd SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection SOIL ABSORPTION SYSTEM (SAS):�� (locate on site plan,if posabk;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: n A / leaching pits,number:, 6jeul r( - CQJ(/ < Q leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields,number, dimensions: overflow cesspool, number: Comments: (note co di ion of soil, signs of hydraulic f ' level of ponju}g, ndition of vegetation tc.) /j/ -S CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped astsinspection Comments: (note condition of soil, signs of by alit failure, leve ponding, condition of vegetation,etc.) PRIVY:_ (locate on site Z Materials of Dimensions: Depth of ds: : (note condition of soil,signs of hydraulic failure, level of poadiag,condition of vegeta ' etc.) (revised 11/03/95) 8 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (V TA Me 8 04(.5 R4 ' &'tl4U Owner: 41 i PW Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 2 � . C9 - c Ala 35 3 DEPTH TO GROUNDWATER Depth to groundwater:,IZI 4- feet method of de'ermination or approximation: 9 (revised 8/15/95) T ~ - .�� FFB. . . .............. THE COMMONWEALTH oF MAssAo*uSErTs U�� _ ��~,", , 'g --' ---'OF--� ------- � Appliration for U^ °K Application is hereby made for u Permit to Construct ( \ or Repair ( ) an ndividual 'Sewage Disposal S . ....- '-.......'......... .....-'-..... ..................... ......................_...............______ _ ................................. .......................................................... _________________' Aa�"� -----.--._-__-----------.._-_.-.--___------'_-- --------~�=°�-.~~~ -~~---- ......................................... Installer Address � Type of Building Size feet Dwelling—No. of Bedroomo----'..3............................Expansion Attic �Vq Garbage Grinder Other—Typeof Building ............................ No. o6 persons............................ S6m=ccv ( ) -- Cafeteria ( ) ~� Other ^ . ~.^~ ----'------''-^---------------------------------------------------------------------------- D � Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Deao8o Performed by.-.-.-..---.-_------_.-.-'------------' Date........................................ Test Pit No. l----.-.miouteeperioob Depth of Test Pit.................... Depth to ground water.--.-.--_._.. 44 Test Pit No. 3................minutes per inch Depth of Test PiL-.------_ Depth toground water........................ uo .__.. -'-_--_.__-_-_--------___________________________________ 0D ofSo�---��"�--��u�wcx�'-----------------------------------.-----------------________,__ ---.-._-''---.---'------__._'--__._'_-_-_---._-------__'--'-__''__-___-----'-'-'--'--'-----.. ............................ �� Nature of orAlb�ud000--Anuwerwbeo --------.--_____-____._.____________ � --__--'-_--'_--''---_''-_'--'_—''--____-_---_-_------_--__''_--_-'-'----'-'-_'_____-_ /q-)le undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witht P visions of'AITAIZ- 5 of the State Sanitary Code— The undersigned further agrees not t(;4the systern in ?a Q. Date Date Date � r ' 2Vm_'�� ' ��m'��:�� .-' THE COMMONWEALTH opMAssAc*usErrs ` + BOAR � for Uhivolial Workg Tomitr tion Urrmit ' � Application is hereby made for a Permit to Construct Kcnair ( lan ' . �,,ndividual ` - ^ ^ �-- Address ...........`........ ........................... --_-----_. - ----- ------�---.=^~_-_ ----'-_---_�__-----'----_.�*" = _ PqIype of � Size Lot � Dwelling yJu c� 8edroomo--_��--_._.----�zyuua�u �ddo � �y Garbage Grinder ( , P4 Dtber--Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) Septic ]unu--Liqou1 /'� .<gal/ooa Lcugcx.-----. Width................�Diameter_............. Depth................ Oi Ircucb--No .................... Widt6-'-----' Total Length.................... Total leaching area....................sq. ft. > ��` Diaueter.................... Depth below inlet.................... Total area............-_sq. ft �� Other Dia��ut�n �/�x( ) Dosing tank ( ) ~~ Percolation Test Results Performed by............................................................... - Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit.-------' Depth to ground water...................... fX4 Test Pit No. l-_-._.minutes per inch Depth of Test Pit.................... Depth to ground water........................ [} Description ' ' � ` --------'' ...................... ---...-...__-_�_--_�---_-.---_.--_--_-'_.---_'_._'-.'---_-__-'_----- '-''--------- .4 U .Nature of Repairs or Afitcca6o6u--Answer when upplicu@�'--------'--_----.--.-------.-'-__-- ------'-_----_----------------_'_-'.''.-'_-----.---,.-____--_--_-'_'_-__-- ' - /Th undersigned agrees to install the aforedescribed* Individual Sewage Disposal System in accordance with t,1� pr isions of T T LE 5 of the State Sanitary Code— The undersigned furthLer agrees not to,phccejhe system in 4/1 % Date ` ' ~ ' ' -'--' Disapproved 'for the following- ----.--'--'-----------r--------'--------'------ .............................................................................................................................................'_----'------__'----__- »"te Permit No - ~.~ � ` . THE COMMONWEA:LTH ' OF mAseAoHus=`T= ' ~ BOARDOF HEALtH - � . ------------'OF.`--'--' -------.---r_----.'--- ` . T °�� °�"°�°"�°° "~ Tom�rI~~°°°~* .r CERTIFY' That t�� Io��v�Juu Sc�x�� Disposal S�o�n/|�constructed ( ) or ( )� -''' ` �\01= -- - ' -'-"---- ` "y.................................................................................................................................................................................................... Installer E 5 o The State Sanitary Code as described in the has been i nstalled in accordance with the provisions of TI*_� 0 upyl�at��for Disposal Works � dated- iqlws � THE ISSUANCE OF THUS CERTIFICATE SHA OT BE CONS RUED AS A G RANTEE THAT THE SYSTEM WILL FUNCT19N SATISFACTORY. ' DATE.................. /� .i .CS.................................... Io- * 'or--' ' ------_- m�ssxo�r*s^ComwowvsALr* OF � SETTS rs . BOARD OF � �i OF---' ............................................`--------- ` Permission, is hereby, granted''^........................................-----------------------....................................................................... ` no Construct ( / or ) uu Individual' S ' at No ` -- --r Street as shown .. the application. for DisposalWorks Construction. Permit ^,. ~~^ ~~-' Dated � . ' ~ _^��_ � ..................... ---'-_- .-_---'--.'--- .. Boar of Health DA7-I�..----.-.�-''�.��'-..--.----................. /uso ` ropw� A. M. su�mw. /w�� ooyrow A. DES/G/V OA 7-4 IVO 6A.2BA45E G•e//UOE.e 3o(. 3 Sz O/.r/42S,4L �/T•-USE /,OIJO 6'/1� . BO TToti1 A.eEd - so S./� — 0 LAOr 7107:44C vE.r/6�t/ _ �1�5 G o. 2 5 7 TOTAL. I>.Q/L}�FLow= 3.34 G.•�o. � � � �x�sT"�J�s �-_ ....� � ' � OE,s/G�/ �EeCOL4T/a�V 7��.' /"/.t/2�/N. ��LE�� i Fo v x)C> i;�f� 14�x _ 1=1- i Ott T) _'5`o RiC .A PEER J;, vo s j qs ` A. '�'y. v� S to BAXTE.R v,.. c� SULLIVAN No.2a()46 No. 2°733 ssr�s�e Nu��' AM�S O'T�� ( `J 1J NAL E 7E.s7-1110A p 271 o IZ.1141r33 . TaNQ Sa c-OU `d l3Ps e.,C k)(e r-v c-. . fG l.o a Alk 6.aL. /.Y✓ BOX /rv✓. G 4L_. �n�u Pir CL53o' S 3.6 SEorrG i • .fTGNE ' `'3'� S3'4' CE,2T/F/EO PGOT ,oL4�t/ r _ 4-7 o LoG,QT/OAV CE1L)Ti:-M,1Uu-QED l�LE i i t3' L-143 j 2S� /Jo W A TLrR.— / GE2r/may Tf/r4T•7;41E aL1A,144 ,1ory Sf-/aWA1 ��^�%L��/�CLC l�iEl� �✓j>S A/VO✓�ETI/�G� ,eEQCJ/�E�IENTS O� Th'E ,2.E6isrE,ec=lJA.�✓�Sl�,eciEyaP,�� i 7OW31 OF 94 Z,vS%9 L L L U� Y 1_ � �'} � •. j Or D c��i � -, T//ls��.a/v i s moo/-- a�Eo a.v ,4/v S�/o K/it/yE,eE4r✓,sc/avG O�pT L� USEp I TaESTf1lL/S,L,� LaT- L./NE,S i. -/,58 LO CAT 10 ' SEWAGE PERMIT NO. �' , �_ / S" VILLAGE I INST LLER'S NAME ADDRES 1 ma'I U I L 0 E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � '� �� B � ,