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HomeMy WebLinkAbout0014 JOHNNY CAKE ROAD - Health 14 ,Johnny Cake Road Centerville A = 210 038 n OPWdinflemop- 152 ORA 10% P2 I Commonwealth of Massachusetts Title 5 Official Inspection Form t, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' S 14 Johnny Cake Road r a Property Address Matthew Pemick Owner Owners Name information Is required for every Centerville MA 02632 B-30-19 r' page. City/Town State Zip Code Date of Inspection { a 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. 0ttttN OF l rip Important:When A. Inspector Information fillingout forms �# ly�� :�:' •,y on the computer, use only the tab James D.Sears ; n _ key to move your Name of Inspector cursor-do not use the return Capewide Enterprises z�'•,o o Company Name key. 153 Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number Llcense Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9-3-19 In tors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5inspdoc•rev.7!2812018 Title 5 QlGdal Inspenbn Form:Subsurlaoe Sewage Disposal system•page 1 of 18 a6ed xez! dH 9E:Ll, 660E t,0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. Cily/Town Slate Zip Cade Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box and three infiltrators 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound. not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.cloc rev.712612018 Title 5 OMlclal Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Z a6ed xe:1 dH 5Z:L 1, 61,0Z b0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name Information is Centerville MA 02632 8-30-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6, 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box.and three infiltrators. 2) 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, NO)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 K a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ NO (Explain below): t5lnsp.doe•rev.712 8120 1 8 Title 50tkial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 E a5ed xe j dH SZ16 6 60Z ti0 d@S Commonwealth of Massachusetts . p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .i 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. ❑ 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): 3) 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. a. 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, 15fosp.doc-rev.NM2018 Title 5 OfTidal Inspection Form:Subsrftes Sewage Disposal System-Page 3 of 18 b a5ed xPJ dH 9Z:L l, 61.0Z b0 daS Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 0 14 Johnny Cake Road Property Address Matthew Pernick Owner Owners Name information is required For every Centerville MA 02632 8-30-19 page, City/Town State Zip Code Date of Inspection C. Inspection summary (cunt.) ❑ 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 b. 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, c. Other: 4) 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 15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c, a5ed x2J dH 9Z:L1, 660Z b0 d@S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i� 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name requinforTn r on is Centerville MA 02632 8-30-19 requiredd for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in s—is less than 6"below invert or available volume is less than 1/2day flow/�' 1111N6 ❑ ® 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 water supply ❑ ® 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 5) 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 C.4. 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 t5insp,doc•rev.11202018 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 5 of 16 9 abed xe:1 dH 5Z L l 6 60Z b0 daS Commonwealth of Massachusetts Title Sewageace e 5Official Inspection Form p y Form for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 B-30-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat,or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? I� ® ❑ 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 15.3O2(5)] tWsp.doc•rev.7I26f2016 Title 5 Offidai Inspection Form:Subsurface Sewage Disposal System-Pape 6 of 18 L a5ed xP� dH 9Z:L 1. 61,OZ b0 d8S X Commonwealth of Massachusetts Ti Sewage tle 5Oficial Inspection Form Susurface p yytem Form - Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: 1500 Gal. Tank - D Box and three infiltrators. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 ears usage 2017-69,000Gals g ( y �gPd))' 2018-61,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date l5insp.doc-rev.7/26120 1 6 Title 5 Official Inapection Form;Subsurface Sewage Disposal System-Page 7 of le g a5ed xeJ dH SZ:L 6 6 60Z t0 daS Commonwealth of Massachusetts k Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�� 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersonslsq,ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to. 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 occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7128l2018 Title 5 Official Inspection Form:SubsuIace Sewage Disposal System Page 8 of 18 6 a5ed xed did 92:L 6 6 602 t,0 daS ram` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F� 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is Centerville MA 02632 8-30-19 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2004 Permit#2004-545. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 30" 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.): Pi ein is 4" PVC SCH - 40. Mnep.d«•rev.7262018 Title 5 Official Inspection Form,Subsurface Sewage Disposal system Page 9 of 19 o l• abed xeJ dH 9Z:L l• 6 60Z t�0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systam Ferm.Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is Centerville required for every MA 02632 8-30-19 page. CltylTown State Zip Code Date of Inspection D. System Information (cant.) 6. Septic Tank(locate on site plan): Depth below grade: 20" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal, Precast H-10 tt Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 0" Distance from top of.scum to top of outlet tee or baffle 8 1. Distance from bottom of scum to bottom of outlet lee or baffle 17" How were dimensions determined? Asbuilt- Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tankat 20" below grade w/both cover's at grade. In and outlet tee's. No sign of leakage or over loading. t5msp.doc•rev.712612018 Title 5 Official Inspecd on Form;Subsurface Sewage Disposal System•Page 10 of 18 �� abed xed dH 9E:L 6 ME b0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments P14Johnn Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page, City/rown State Tip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cant.) 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 9. 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 is 16"x16"-3'below grade wlcover at 18". Box is clean and solid wlone line out. No sign of over loading or solid carry over. t5insp.doc•rev.7,2612018 Title 5 Official lnspeclion Form:Subsurface Sewage Disposal System-Page 12 of 18 Z 6 abed Ye d8 d dH 9ZL 6 6l•OZ b0 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name irmation is nfo every Centerville wired for eve MA 02632 8-30-19 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (1)12'49 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.712612018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 16 E l• abed xed did 9Z16 We t,0 daS Commonwealth of Massachusetts UV_ Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pemick Owner Owner's Name information is � Centerville required for every MA 02632 5-30-19 Page. City/Tcwn State Zip Code Date of Inspeeion D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three infiltrators. Ck D Box-Prob area and camera out line. No sign of over loading or solid carry over. No sin of holding water. 12. 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.): t5insp.doc•rev.7/262018 TIVe 5 00cial Inspection Form:Subsurface Sewage Disposal system•Page 14 of 18 tit abed xed dH W:L 1, 6 60Z t,0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 14 Johnny Cake Road ' Property Address Matthew Pernick Owner Owners Name equired ion Is required for every Centerville MA 02632 8-30-19 r page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev 7128r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 5 abed xed dH 9E:L6 660Z t70 d@S Commonwealth of Massachusetts QNRN.mp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. Clty]Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 a AFAR S Mnsp.dac•rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewege Disposal system-Page 16 of la g a6ed xed dH 9216 660Z t70 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� 14 Johnny Cake Road Property Address Matthew Pernick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 15. 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: 9-8-04 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: T.H,on Design plan 9-8-04-12'+ no G.W.. Bottom of leaching at 4' below grade. Bottom of leaching at 8'+above G.W. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/284018 Title 5 Otfldal Inspection Form:Subsurface Sewage Disposal System-Page 17 of is Li, abed xeJ dH LZ:L l, 6 60Z t70 d@S c `y Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments V 14 Johnny Cake Road Property Address Matthew Pemick Owner Owner's Name information is required for every Centerville MA 02632 8-30-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® G. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For B:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included G�AD� T. .4 EAC & /N�o t5insp.dcc rev,7126/2018 Tide 5 Dfflcial Inspecdon Form:Subsurface Sewage Disposal System•Page 18 of 18 96 abed xeJ dH LZ16 660Z t,0 d@S TOWN OF BARNSTABLE "� �;, �► LOCATION 141 - SEWAGE # Q'q' VILLAGE ASSESSOR'S MAP/& LOT 1 U3 S( INSTALLER'S NAME&PHONE NO. r. SEPTIC TANK CAPACITY . 6 500 LEACHING FACILITY: (type) A QMtP-.K, (size) .� �✓ NO.OF BEDROOMS BUII.DER OR OWNER 'TY 4, a PERMTTDATE: �� I COMPLIANCE DATE: 10 Q Separation Distance Between the: v Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist / within 300 feet of leaching facili ) ��7 /A Feet Furnished by 1 ,. No. aW L4 5`L-5 Fee ' e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, M!ASSACHUSETTS 01pplication for Dfi5po l 6potem Cuttetruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( /� Abandon( ) IJ Complete System ❑Individual Components Location Address or Lot No. 114 colz, aiOwner's Name,Addy and Tel. Assessor's Map/Parcel a1 003R Installer'®e,Address Te1;No.� �6 — yc1tL4 __L Designer's Name,Address and Tel.No. 7-7 S Type of Building: Dwelling No.of Bedrooms 3 Lot Size 1 60 sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow �;g 0t 0 gallons. Plan Date QI Number of sheets Revision Date Title Size of Septic Tank S400 Type of S.A.S. Sutx� _it_?nncAo Description of Soil 3w-d, Nature of Repairs or Alterations(Answer when applicable) Q - ,..... Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Si ed Date Application Approved Date O `7 Application Disapproved for the following reason Permit No. Date Issued -- ------- --- _� r Fee No. � `�4 a j THE COMMONWEALTH OF MASSACHUSETTS ;Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., IIIsAS'S ICHUSETTS'`' �rc ZIpphration for ;Digogai Opotem Congtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade(V)Abandon( .) In Complete.System ❑Individual Components ,I Location Address or Lot No. C0im Owner's Name,Ad ress and Tel.No. 61Y" & ' Assessor's Ma /Parcel Vv ` � p a o03 �� , il� T11e'L�Name,Addres at Tel.Nod 36 a' y�LI �� Designer's Name,Address and Tel.No. -77 Type of Building: Dwelling No.of Bedrooms 3 Lot SizeGoo sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow S30 gallons per day. Calculated daily flow -:;$Q1 . U gallons. Plan Date 9 b u Number of sheets Revision Date ." Title Size of Septic Tank Type of S.A.S. SZa e� �/i_VA6 mot; Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,,,,,., Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. S' ned ` Date 16 Application ApprovedL. Date /d i,51ci Lf Application Disapproved for the following reasons Permit.No, '- .'��7 Date Issued 6 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( )Upgraded(1/) Abandoned( )by ` at has been constructed in accordance with the provisions Qf Title 5 and for Disposal Sgstem Construction Permit No.9 du Q Y dated jj Kljy Installer Designer The issua ce of this er;nit0hall not be construed as a g uarantee that the s st- will- nction as b i. ned Date �p �!0`► Inspector y I "J K No. y 5 '7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS liopool *pgtem (Zongtruction Permit Permission is hereby granted to Construct( )Repair(✓)U r e( )Aba and System located at �OA;Tm and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction muy be completed within three years of the dat o�f this perm' Date:_ /0/I ©� Approved by —� r 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, p29 A,' ,�,�,J ,hereby certify that the engineered plan signed by me dated concerning the property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are.no commercial or business.uses associated with the dwelling. • The.soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information). 8• s B) G.W.Elevation +adjustment for high G.W. _ DIFFERENCE BETWEEN A and B SIGNED : , r•�. DATE: Ct— NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexerM.doc TOWN OF BARNSTABLE LOCATION SEWAGE # 0'4 5 q 51 � . VILLAGE ASSESSOR'S MAP &LOT 210� �3 INSTALLER'S NAME&PHONE NO, SEPTIC TANK CAPACITY 5 LEACHING FACILITY: (type) Onnr ._, (size) ���' " NO.OF BEDROOMS BUILDER OR OWNER In Cm, PERMIT DATE:�101 �' �COMPLIANCE DATE: l0 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 �� Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist /A Feet within 300 feet of leaching facili ) F shed by ii 014 v1 i I Dec 16 04 11 : 53a Daniel E. Braman PE 508-362-6016 P. 1 1'L/lb/Lk7YSb 11:L3 7t7tf I!btl/:1N wGLL.crs HJJVb au- 'J1 Town of Ra rnstlsblc Regulatory Services d s Thoum F.GeNer,Lector Public Deahh Division Thomas McKean,Director 200 male strft%Syseanls,MA 62601 ' Fax: �8-79(8.6304 Odra: SOB-862.4644 • Installer&Ikeiaer C 1P'o Date: z '„1!6--- �,yyyy e W—) gles�er: .A _�' � Installer: y� A.ddress: on �0(d ®� was issued a perzit to iWlall a : �) 4ffi or septic,system at based on a design drawn by ad s) dated._aIsl"1�—sr-� V I certify that the septic system refemnced above was installed substantially accordiug to tlae d:esip,WWch may include minor gproved cbanges such ®a lateral relocation of the distribubou bore and/or septic tom. I oer4ify that the septic systm raft w above a Wstailed"vidt major chasms Cur 1 tlsan 14' Lamm relocation of the SAS or say vertical relocation of any componevt of the septic system)best in accords with State&Local&te�talatians. Ply rt�n�or c efiad as-built by designer t8 gO11AW. DANIEL E.BWAH rm� ® STRUCTURAL W 30695 �esign a Sr — Doi gn s bt=P ) TURN tvE P � ® Y �a IBM- 471tenlWS Vs calwastm FOM . j rri C1t Pi�OcILE NOT TO' SCALE T DJTT 1-10L_E L_OO R T LAKE 2-LAYER Of- PEA5T0W ELs h9.5 MRST PIPE LENGTH OVER'5/.4--I V2-POUCLE fi 60VERS TO WIN TO bE !�T LEVEL WASHED STONE�=A Ar b" Cr rIN�WITHIN rOR MIN. x DATE: SEPTEM15ER 5,2.00.4 �1� r�NISH eRAt TEST f5Y: M.O'LOL&HL IN,GSE j EL=�b.5f PERG RATE: <2 MIN/IN $' 11" PV �A' PVC TOP 0 tt A5.7 '+0 A8.3 OR6AW. 2„ °1 Ay 5 A5,75 A50 ' W TOM A H_ A13DO A p=LOAMY SAND 400a n+ WrLp s� mtrrt A5X1 DKT. D09f ��a rYR,4/2 S„ �` A515 vA1 t ON 7 5EPARATION b Pp� dw=LOAMSANP 5E''�: TANK WOM Or EST har ® m-Ev. �D k'JYRSY b �' sr� t�ASe rT T �6.5 pOTTOM Or PERG TEST®AO" G=60AR15C SAND LOGAT-I ON MAP DEs I CAN DATA 2.5Yb b PAILY FLOW: (3)15EDROOMS x 10 GPD=330 GPD 36 0 15d' SEPTI G TAN K: 330 GPD x2007.=660 GPD USE: 1500 6AL.PLASTIC SEPTIC TANK NO WATER ENGOUNTEREP LEACHING FAG I L(TY: CAPACITY: a ` 51C�EWALL: 8 3,z x z X o 7/= IZ3, o - Ana OENERAL NOT.S I. CONTRACTOR TO M RESPONS115LE FOR THE LOCATON OF ALL UTILFIES, Af5OVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. < 2, SEPTIC SYSTEM TOM INSTALLED IN COMPLIANCE Wf'H 310 GMR 15DO:TITLE V 3. THIS PLAN IS NOT TOM USED FOR PROPERTY LINE DETERMINATION ,$O a .4. ALL DISTURPED AREAS TO M LOAMED AND SEEDED .� . _,: .-. «,�, Vi es 1-4 i}i ? T.l ,'* I�.F Fr1� /�!4v REOI I I .I- CGT f O1\IS. // QQ o a N f? D I NSP 6. EX IST I NCv CESSPOOLS,ALONG W FH ANY CONTAMINATED 501 LS,TO M REMOVED. �a Q o 0 �TY TE �EVVAaE FLAN LOCATION: 14 JO1 iNNY CAKE RP., OENTERVILLE, MA \ \ + PREPARED FOR:._G-'1zn/E,ST-�_.mac-',8c-,rL�'_�:•�. SCALE: DRAWN 15Y• �S 7 or �o�,a DAt�l1"L BS6c'��`� _ 2d TMW STFVF r`s s BRAMAI` ��p i \\ R nr- W. `^ i CIVIL x� DATE: SHEET: 9, -J �, . szs8 C JOB NUMBER: \ I OA-093 09-1,4-WO.4 SP � _2A o4-- .4� WELLER & A6600 I ATE6 j I645 FALMOUTH RP - SUITE -40 OENTERVILLE, MA 02Un TEL.: (505) 775-OT35 N FAX: (505) 775-0754 PROFESSIONAL ENGINEERS & LAND SLRVEYORS