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Home My WebLink About0135 JAMES OTIS ROAD - Health 135 FAMES OTIS ROAD, CENTERVILLE A= 170 155 )�)// � 2J�gECYClFp UPC 12543 No.535 LOR �srcoNS� HASTINQS,NN I I I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , yr� 135 James Otis Rd. Property Address 0 Zottoli Owner information Owner's Namet is required for every page. Centerville MA 02632 5/18/18i City/Town State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered'in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 5/18/18 Inspector's nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 135 James Otis Rd. Property Address Zottol i Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N FIND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 James Otis Rd. Property Address ZOttoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water 3 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 James Otis Rd. Property Address ZOttoli Owner information Owners Name is required for every page. Centerville MA 02632 5/18/18 City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 L15,.s.do,•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s a 135 James Otis Rd. Property Address zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 CityrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2013 Per owner P Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1/18/85 compliance Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound 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: 3" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle >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 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 years to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 135 James Otis Rd. Property Address Zottoli Owner information Owners Name is required for every page. Centerville MA 02632 5/18/18 CityTrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box 2' below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface -Sewage Disposal System Page 12 of 17 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 135 James Otis Rd. Property Address Zottoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was video inspected, effluent level is approximately 2' below the invert, no indication of past hydraulic failure, top of pit 3' below grade, cover raised to 18" Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 James Otis Rd. Property Address ZOttoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 CityfTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Soils are compact and dry Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 135 James Otis Rd. Property Address Zottol i Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 2 y 2 LA Lk t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 James Otis Rd. Property Address ZOttoli Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 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: >12 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: 1985 compliance Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Prior inspection on file GW>30' ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 James Otis Rd. Property Address Zottol i Owner information Owner's Name is required for every page. Centerville MA 02632 5/18/18 CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN//O//F BARNSTABLE LOCATION /�<�- J�9S �ai� SEWAGE # -VILLAGE ASSESSOR'S MAP & LOT 1170"�•7 J�J liVSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY dOQD --A -", LEACHING FACILITY: (type) �� '�� (size) Off NO.OF BEDROOMS :5. / BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leachin X- 19,4 Furnished byl i`35 »e;, O4 i3 DATE : 4/3/98 PROPERTY ADDRESS:_135 James Otis-Road Centerville, ------------------------ Mass . ------------------------ On the above date, I inspected the septic system at ,the ae address. This system consists of the following: I 1 . 1 -1 000 gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. f Based on my inspection, I certify the following conditions: 4 . This is a title five septic sytsem. ( 78 Code ) 5 . The septic system is in proper working order at the present. V 6 . The septic tank has been maitained on a maintenance program. The tank has been every three years since 1988 . SIGNATUR �- Name :- J .-P. -Macomber-jr. Company:Joseph _p,_ M�comter 3 Son, Inc. Address:__BQx _Ej--_--------- __ ry1-ll-Q-,-.M a--Q2 6 3 2-0 0 6 6 Phone: 5 0 8-7 7 5-3 3 3 8 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY rJJOSEPH P. MACOMBE:ah SON, INC. Tanks-Cesspools-Lfields Pumped & Ined Town Sewer Cotions P.O. Box 66 CentervilleA 02632-0066775-3338 7712 • COMMONWEALTH OF WSSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. h1A 0:108 617-29'-��00 �'ILL1.4�1 F 'ELD ?c Govcmor D `• = '3 S1 ARGEO PAUL CELLUCCI Lt.Go%cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �`T " PART A CERTIFICATION Property Address: 135 James Otis Road Centervill@ddress of Owner: Date of Inspection: 4/3/98 (If different) Name of Inspector: jnsp=h P_M;;comber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J"P.Macomber & Son Inc. Mailing Address: BOX 66 Centervil_1_P,Mass_ 0 632 Telephone Number: up_77 n, 3_�3 8 CERTIFICATION STATEMENT I cenif That I have personally inspected the sewage disposal system at this address and that the information reported belo�, is ;;_e jccu and complete as of the time of inspection. The inspection was performed based on my training and experience in the proaer .r c r a maintenance of on-site sewage disposal systems. The system: ,Passes Conditionally Passes _ Needs Funher Evaluation By the Local Approving Authonry Fails J Inspector's Signature Date: /XK--' // V The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of comp4e,1n3 t-),s Inspecl'on If the system is a shared system or has a design flow of 10.000 god or greater, the inspector and the system 0er <.r.311 s-. the report to the appropriate regional office of the Department of Environmental Protection. The original shoo d be sent to �-K s,ser� o and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or U YjZ AJ SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as definedin 3'C Any failure criteria not evaluated are indicated below. COMMENTS: — BI SYSTEM CONDITIONALLY PASSES: yr One or more system components as described in the "Conditional Pass" section need to be replaced or ri 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', expl :n . r, nc The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Ce-, cafe : Compliance (attached) indicating that the tank was installed within twenty (20) vears prior to the date o :r-O- r s rc o the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or (!x-.i1.ra:Ior failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conform:nz sr •; c as approved by the Board of Health. tr.vi..d 04/25/97) Paq. 1 of 10 DEP on the worto wide Weo. hnp 1twww.ma9net state ma uvoer n Pnnted on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR•', PART A CERTIFICATION (continued) Properly Address: 135 James Otis Road Centerville,Mass . O"ner: Joseph Argento Date of Inspection: 4/3/98 e) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box 15 due :. Dro<en _ pipets) or due to a broken, settled or uneven distribution box. The system will pass insxc',ion i Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four limes a year due to broken or obsuuc7ed o pe s Tne s+s.eT ,nspect,on 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: 41 Conditions exist which require funher evaluation by the Board of Health in order to determine if one ss Stem is 'a: •c :: - public health, safety and the environment. t) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: NU Cesspool or pi ty s within SO feet of a surface water Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt m.arsn :) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROrR!ATEt DF1:.2'•+; •i n THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFE-1 AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee� c a s_n,ce tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a o-Dhc The system has a septic tank and soil absorption system and the SAS is within 50 feet of a f� The system has a septic tank and soil absorption system and the SAS is less than 100 feet !rCl :)r -_rr private water supply well, unless a well water analysis for coliform bac7eria and �olaide orga-,: corn:o-rcs the well is Iree from pollution from that facility and the presence of ammonia nitrogen ana n :ra-e n,:rc;.•- less than 5 ppm. Method used to determine distance (approximation not val.d 3) OTHER 3 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.H PART A CERTIFICATION (continued) Property Address: 135 James Otis Road Centerville,Mass . Owner: Joseph Argento Date of Inspection: 4/3/9 8 D) SYSTEM FAILS: You must indicate ew er 'Yes" or "No" as to each of the following: L I have determined that the system violates one or more of the following failure criteria as defined in 3'0 C.»R 15.303 rc oas's for this determination is identified below. The Board of Health should be contaeied to determine what will be necess.:r. cOnec. the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ciogge• »: o- cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or cloggec SAS or cessaoc — e k l �01 Liquid depth in GeSi•peel 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 pipes) Number of times pumped(Z Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface -titer s.,c_ 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 prisaie water suppl .,el - .r nc acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well waver ara , is for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Q LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: A� The system serves a facility with a design flow of 10,000 god or greater (Large System) and the system is a signiiica.n! ;rive;; !o public health and safety and the environment because one or more of the following conditions exist Yes No the system is within 400 feet of a surface drinking water supply �f1/¢ 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 Protecaion Area • IwPA) or a mapped Zc-t= public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater trea!Ten; :. z ar requirements of 314 CMR 5.00 and 6.00. Please consult the local regional oHice of the Department for further information (r.vl..d ➢.y. 3 of 10 l \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 135 James Otis Road Centerville,Mass . Owner: Joseph Argento Date of Inspection: 4/3/9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No , Pumping information was provided by the owner, occupant, or Board of Health. 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 recent'\ or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,Acluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if djfferent from owner) were provided with information on the proper mainienance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) Pia9• 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' Property Address: 135 James Otis Road CEnterville,Mass . Owner: Joseph Argento Date of Inspection: 4/3/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow:110--$.p.d./bedroom for S.A.S. Number of bedrooms: .Number of current residents: Garbage grinder (yes or no):.&4? Laundry connected to system (yes or no): Seasonal use (yes or no)Iez- \eater meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): / Z" 9 ,4W Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: ,�14 Design flow:AW gallons/day Grease trap present: (yes or no)&24 Industrial Waste Holding Tank present: (yes or no)A,, } Non-sanitary waste discharged to the Title 5 system: (yes or no)4v—A Water meter readings, if available: AIX AVA Last date of occupancy: OTHER: (Describe) &4 Last date of occupancy: AM GENERAL INFORMATION PUMPING RECORDS and sour of inforfnat,, YIRJTE+��r4C1P F [-C/7 ' l," /�/lf��I/ Y'�" �Xy� �t' - , c1 ' �C> IT_ System pumped as part of inspection: (yes or no)_ If yes, volume pumped: 4M gallons Reason for pumping TYPE 9S,SYSTEM V Septic tank/distribution box/soil absorption system /17 Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) AW I/A Technology etc. Copy of up to date contract? Other 61, APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (r.vi..d 04/25/97) P.g. 5 of 10 fe) V mme: Joseph Argento 944-8230 924-4969 CUSIMW co": Adam: 135 James Otis Road jarg Tam: Centerville state: Ma zip:02632 add": 135 James Otis Rd Centerville MA 02632 12/19/88 pump T 70.00 12121/88 10/1/91 pump T 105.00 1014191 11/8/94 pump T 135.00 11/10/94 9/19/97 pump T 145.00 09/25/97 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 135 James Otis Road Centerville,Mass . Owner: Joseph Argento Date of Inspection: 4/3/9 8 BUILDING SEWER: (Locate on site plan) tl Depth below, grader Material of construction: cast on 40 VC other (explain) Distance fro m //— private water supply well or suction line _ Diameter Comments: (condition of joints, v nting, evidence of leakage, etc.( A. SEPTIC TANK: (locate on site plan) Depth below grader Material of construction: Zoncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age) Is age confirmed by Certificate of Compliance A(Yes/No) Dimensions: 6st-'4'VI yid/� ✓�� ,u`�l Sludge depth: _ Distance from top ofsludge to bottom of outlet tee or bafile Scum thickness: /I/P 2_ Distance from top of scum to top of outlet tee or baffle:7�— e. Distance from bottom of scum to botto of outlet e or baffle: i4L� III How dimensions were determined: Comments: (recommendation for pumping, conditi of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc �' — " r r.v wo �4 GREASE TRAP:AAD'-'e (locate on site plan) Depth below grade: Material of construct ion.e/Yconcrete'VpmetalV19Fi bergI ass 41APol yet hylene.V other(explain) U* Dimensions: J/ Scum thickness: A) Distance from top of scum to top of outlet tee or baffle: .VA Distance from bottom of scum to bottom of outlet tee or baffle:_42a Date of last pumping: ti/� 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.) (revimed 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 135 James Otis Road Centerville,Mass . O ner: Joseph Argento Date of inspection:4/3/98 TICHT OR HOLDING TANK: tJe.e (Tank must be pumped pn(jr to, or at time, of -specion) (locate on s.te plan) Depin 0elovv grade ;)/l Matet�al of construClion:,vj4concrete,(`metal, Fiberglas54)pPol�,ethylenerV_4other(explain) A — AM - Dimensions A"A Capac'r/ CA gallons Des,gn 1,10" A1A gallons/day Alarm ie,el CA Alarm to working order, Yes,441 Nu Date 01 previous pumping: Comments (cond,00n of nlet tee, condition of alarm and float switches, etc ) Pd i»T 4119L ) DISTRIBUTION BOX: tloca:e r s,:e plan) Dep:n I.,,,d level above outlet mven G) COmmer.:s tnote o level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) A.,s! PUMP CHA.1-IBER: 4Lr- (Iou:e on site plan) Pumps n -orkmg order: (Yes Or NO) NIi Alarms ..n •,ork,ng order (Yes or No)—&-N Comments incite Condition of pump chamber, condition of pumps and appunenances, etc.) ��,,n,n /JI1cs:M oin IS X)Q; F,g• 7 of 10 SUBSURFACE SEWACE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFOR&,ATION (continued)" Property Address:1 35 James Otis Road Centerville,Mass, Owner: Joseph Argento Date of Inspection: 4 3 9 8 �) r SOIL. ABSORPTION SYSTEM (SAS): 4�/�AKn' �Cc14s ;locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive memoos) If not determined to be present, explain: Type leaching pits, number; leaching chambers, numbe leaching galleries, number: �i leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: lJ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) A-6 r•y. "fA2-4 1 e --- 1 ----- CESSPOOLS: '641r- (locate on site plan) Number and configuration: Q Depth-top of liquid-to inlet invert: j /i Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: 5 Indication of groundwater: N inflow (cesspool must be pumped as pan of inspection) DDd $ 7ZVI ,<eo - - -- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:Allxt'i (locate on site plan) Materials of construction: D:mensio.-:s Depth of sohds.A�� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) tr.vi..a o./�s/sal P.9. a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORns PART C r SYSTEM INFORMATION (continued) Properly .;cdress: 135 James Otis Road Centerville,Mass . O"ne' Joseph Argento Date of Ins.,)ec6on: 4/3/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: ,!-;i.,ce ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) lr•v:..7 :�/2f/f7) P. 9 of 10 SUBSURFACE SEWAGE DISP t SYSTEM INSPECTION FOR.tit 1 C r SYSTEM INFOI: !ION (continued) Property Address: 135 James Otis Road Centerville,Mass . Owner: Joseph Argento Date of Inspection:4/3/98 Depth to Croundwater.I Feet Please indicate all the methods used to determine High Croundwater Elcl.a.,on: Oolained from Design Plans on record __j/—/ ,on o tie A .Wing property observa tion hole, basemet'simp etc.) r- V Determine it from local conditions Check with local Board of health Check FEMA Maps _Check pumping records _zCineck local excavators, installers Use USCS Data Describe n your own words how you established the High Croundwr«:levation. Must be completed) Used Water Contours Map. Gahrety & Miller 12/16/94 Ir•vi••C 01/73/97) P•S lbuf 10 I TOWN OF Barnst-ahl P WARD OF HEALTH SUBSURFAU SEKA(IF DISPOSAL SYSTEM INSPECTION FORM - PAfz,r U CF.ItTIFIC TIUt �• '.. t. -t .•. •—�„I.��T.T. '+,�.TT,TT'.T.T./TTn-..—•.-1^1,1Tw11fT'IVP•'•T',n'TiT.R T� Tnf,nir"-r+".iT��+.r-r —ter— r-.- -TYPE OR PRINT CI.EARLY— PROPERTY INSPECTED STREET ADDRESS 135 James Otis Road Centerville,Mass . ASSESSORS MAP , DLOCK AND PARCEL OWNER' s NAME Joseph Afgento PART D - CERTIFICATI011 NAME OF INSPECTOR Joseph P.Macomber Jr. . COMPANY NAME J.P.Macomber & s6ri Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Stravl Town or CSty Stat• c!. COMPANY TELEPHONE ( 508 1 775 - 3338 FAX ( 508 1 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dispose-1 system this address and that the information reported is true , accurate , and complete as of the time of ..inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance c o. site sewage disposal systems . Check one : __ZSysteai' PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any fail ,l :'(2 criteria not evaluated are as stated in the FAILURE CRITERIA sec .; u:) o : this form . System FAILED* The inspection which I have con �Icted has found that the system t Protect the public health and the environment in accordance 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . r 1 Y l Inspector Signature ` Date One copy of this certification must be provided to the OWNER , the BUYER ( where applicable ) and the 130ARD OF 1i8AL'I'll . If the inspection FAILED , the owner or operator ehalI upgrado the eya within one year of the date of the inspection , unless allowed or renul -e otherwise as provided in 310 CMR 15 . 305 , w 1 7 - � y THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 . 340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June R. 1995 Acting Dircct< r of thc 61011 ()I Water P0111111on UnIIUI lam. 1"to G T ION j SEWAGE PERMIT NO. - ?� �4 VILLAGE �c IN A LLER'S NAME i ADD ESS N _.t 'r 13 c ; ® U I D E R OR OWN ER DATE PERMIT I S S U E D 14- - 164 DAT E COMPLIANCE ISSUED . �� J�r-e..1^ '�a.c..l .. -� W y '<' „� �9 ' � �� a i 3�- �, o ,