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HomeMy WebLinkAbout0055 JUNIPER ROAD - Health 55 JUNIPER ROAD, CENTERVILLE A= UPC 12534 No.2_ HASTINGS,MN Commonwealth of Massachusetts I � ,w Title 5- Official -Inspection Form ; ► Subsurface Sewage Disposal System Form Not for Voluntary Assessments . f 55 Juniper Rd ' 1�y.V Tfy. �w+.. Property Address k Pat Montimurro Owner Owner's Name r- information is `,;, required for every Centerville MA 02632 5-24-18 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. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Eval b e Local Approving Authority 5-24-18 Irispector's 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 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 God VS 9 Commonwealth of Massachusetts ' Title 5 Official Inspection Form i.i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System-Passes:, - r ® 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form irk Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town 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 El ❑ 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc.•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts 3� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 c Commonwealth of Massachusetts 3, Title 5 Official Inspection Form �-r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts ,3p Title 5 Official Inspection Form i 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :• `�' 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 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? ® ❑ Wasthe 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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IC► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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: 5-2018 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): canons 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 ,I w_ --i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r f�, 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 8-2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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 it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"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: 1000 gal Sludge depth: 6" t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. Cityfrown 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 26" Scum thickness 0 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 16" How were dimensions determined? Tape 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 in good condition with baffles installed and no sign of leakage. 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 u 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 C4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 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.): 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form 'Ib'i Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments ,k 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is Centerville MA 02632 5-24-18 required for every ' page. City/Town 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.): Good condition with water at working level and no sign of back-up from field. 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.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 s Commonwealth of Massachusetts r� Title 5 Official Inspection Form -ll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Infiltrator 3050's ❑ 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 field in good working order and empty at inspection with no sign of back-up into d-box or surrounding stone. 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 1.1' Title 5 Official Inspection Form 'o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville' MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t I, t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 C Commonwealth of Massachusetts �. Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town 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 109 140W 6 (0 L � f 37 A,�Y_ 4/ 4101: 7� #6 c' 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 �i�bi. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town 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: 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: Original design plans show no groundwater at 12'. 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 Oil Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Rd Property Address Pat Montimurro Owner Owner's Name information is required for every Centerville MA 02632 5-24-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name ; information is required for every Centerville MA 02632 October 14 2015 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information C ✓/� ��2� 2 on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response Q Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 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 Coca- 44, October 14, 2015 Inspector's 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced-or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. City/Town 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 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 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 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water 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: J 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 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. Cityfrown 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•3/13 Title 5.0fficial Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. Citylrown 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 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 1 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A system sized for three bedrooms was installed by Robert Aalto in 2006. Number of current residents: 0 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)): 85 gpd Detail: 2013: 39,000 gallons 2014: 23,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: 1 week ago 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 9+ years. Certificate of Compliance for a new system was issued 8/3/2006 (Permit#2006-343 at Health Department). 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer lines appear structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 x 5 x 6-1500 gallon Sludge depth: 4 in t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan 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 not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14 2015 page. City/Town 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching gallery stone and no effluent contact staining was,observed in the stone or overlying soils. No standing effluent was observed to a depth of 12 inches below the top of the stone layer. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 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 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14 2015 page. Cityrrown 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 01- Q�S 1500 GALLON 4 SEPTIC TANK ' ! O - 2 LEACHING GALLERY NOT TO SCALE B A EMS TWIG THIS SKETCH IS �p��oo BEST VIEWED IN D�%�%CEL�L 9�IG COLOR FORMAT 5� PA VED DRIVEWAY LOoCA §OoNS z °T —OF SEPTIC COMPONENTS or —DISTANCES IN DECIMAL FEET w A B Q 1 47.5 16 "`, • 2 40.5 23 3 34 32 4 18.5 58.5 508 364-0894 JUMPER ROAD t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is 10 feet above the elevation of Lake Wequaquet-a controlled elevation lake. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Juniper Road -Assessor's Map 210 Parcel 114 Property Address Kevin and Sonia Lombardi Owner Owner's Name information is Centerville MA 02632 October 14, 2015 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE a ai - BOTTOM OF o LEACHING GALLERY LEACHING IS ABOVE HIGH OAOUNDWATEA d GROUNDWATER ELEVATION PER GIS MAPS i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN 0 g.��ti`ISTABLE SEWAGE# LOCATION .-. t1+e� ASSES o��S ► LOT Tam'§P 4�N SB1�T'[C �CARP d 0 -. A '. 7 Arar csixe) 3 3 LEA►CMW Faces { ) ..._ rro 777.7oor�� 3: h3tJII:Dit 4R O`NriF.R PEht1F�DATE GO1Vlh'T:tANCE Sepaitauon Dcstance Betwtenahc. Feet MaximumAdjusteslGroundwaterwUbleto t :Bosom ofLeac Mg*. Oeitity PmrafG' Cater Supply;Well andLeas ng saw. :tlE anyes.exist on sits or withun?Ao fcet of beaching faciEy) Edge q£V�letlan and°1.eachltn$Faa'ltty(If any�rctlaiids exist d Piet wittuat 3l3(}feet n :leaching!a«2it1►� 1 t r ELD-3 A,a - 3 7 ' A,3 - 3 0 19 .3 `T' Nor. C?a 6 L/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipphratiou for Dizpozal 6p5tem Cowaructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. t,° Owner's Name,Address,and Tel.No. Ce-/Ar Assessor's Map/Parcel �JL Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 6OS Dwelling No.of Bedrooms 3 Lot Size 98�/' sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided ��� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil s-ee• 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 Certificate of Compliance has been issued by this Boa th. Si ed Date '" —C Application Approved by, Date Application Disapproved by: Date for the following reasons Permit No. 3 Date Issued Yam•^ No. GO' t.D — 3 �/ 3 ` Fee / O d THE-COMMONWEALTH OF MASSA7CHUS TTS Entered in computer: tt/ PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS :Yes 21pprication for � gpogal �§pgtem Congtruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. S ,� Lh Owner's Name,Address,and Tel.No. /rp✓,'vt 6vv»,hp.c/ Assessor's Ma /Parcel p Q117 Installer's Name,Address,and Tel.No. oe Designer's Name,Address and Tel.No. �0. /�X 33 9 gym• y7��s ti!%/riN�} a �,�yam. �,, �" _ Type of Building: �Og Dwelling No.of Bedrooms 3 Lot Size 99 L/'7 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min,required) 330 gpd Design flow provided 3�io gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 5 � �� ,•-� 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 Certificate of Compliance has been issued by this BoardSf- th. Si ed Date '� —Cr 4 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS . (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by ) C. ? 17"a Cam > at h J-1 el ;/JET R14 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Now G 3 (1/ dated Installer A)c #0 Designer��v� ���� AssflC. #bedrooms 3 Approved de?g4iflilov 3 3 L gpd .t 1. The issuance of this permit shall not be construed as a guarantee that the system will func ion as'dnesigned. t�>C Date I���� _ _ Inspector { V" -----------[—�-------------- No. �ooG 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migont &pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (1/ Abandon ( ) System located at 5-5- ,�v 0 'W e v and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditio s, Provided: Construction m st�b'completed within three years of the date of this pe Date r/ Approved b Town of Barnstable Regulatory Services - z Thomas F.Geiler,Director � 63 Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Offi6e: 508-862-4644 Fax: 508-790-6304 Installer&Designer CertiScation Form -7 �.s y 'V\jk P 7A D 1 i Date: '9?" —0 6-v C. Designer: bwtaller: D ASSOCLATES Address: 42 CANTERBURY LANE Address: 608/540.2534 '< On o '3 -Ob - 1 ��.1► A 1-1-'p was issued a 't to (date) �. P� install a septic system at b ��1 t.� L r _"Zy bas�on(�) a design drawn by i s o dated (des er) _\ZI c that the septic system referenced above was installed substantially according to e design, which may include minor approved changes such as lateral,relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical'relocation of any component .` of-the septic system)but in accordance with State&Local Regulations.. Plan revision or certified as-built by designer to follow: H OFq�gs�q ►►AAOF ���� ��� O1RISTINE �yG^ i�S��a�G\STEgFS4cfr��I OnSi -r7SS Signature) �IRNENY. CJ tio,9�g ti STEPHEN GISTE o DOYLE ► a SANITAR�a� � \o�'�� i _L:� aJA74&4 esi er's Signatiue) (,Affix Designer's Stamp ♦ ��.� PLEASE RETURN TO BARNSTABLE.PUBLIC IEALT DLVISION. --CERTIFICATE OF COMPLIANCE RHLL NOT BE ISSUED'.BOA-TES:FORM AND AS- BUILT CARD ARE RECEYVED BY THE BA3ZNTABIEDBIIC=°B[EAI,TIE$DSION. THANK YOU. Q:HewMepticMesigaer Certification Form Town of Barnstable P it Department of Regulatory Services f R&RNUUBM : Public Health Division Date 0, t-Z,-- o M �639. 200 Main Street,Hyannis MA 02601 Date Scheduled Time �� Fee Pd. Soil Suitability Assessment for Sewage Di sal Performed By: I�:f.�� Witnessed By_ LOCATION& GENERAL INFORMATION Location Address l f / Owner's Name k ial.a I l�t%,i2. '��voe P� L•Ol�+'� Address sA1-Ar✓:L1 Assessor's Map/Parcel: Engineer's Namea� �. . NEW CONSTRUCTION REPAIR � .Telephone# �V�j � O Land Use Slopes(%) ����J Surface Stones Distances from: Open Water Body T e ft Possible Wet Area ft Drinking Water Well 7 1 0 ft Drainage Way T r"A ft Property Lane S &U ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) Lve Lve o-� 1 � ge� ti�-r�n KS Parent material(geologic) Depth to Bedrock �e C. Depth to Groundwater Standing Water in Hole: 11 -- Weeping from Pit Face Estimated Seasonal High Oroundwater DETERNIINATION FPR SEASONAL HIGH WATER TABLE Method Used: _ D Depth Observed standing in obs.hole: ,,_in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment fi. Index Well# Reading Date: Index Well lev — .m..,. Adj.factor s� Adj.Groundwater Level PERCOLATION TESL' D1110 1 .1 TIMOJILds Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ 'lime(9"•6") End Pre-soak �� i Rate MinJlnch G� r °f Site Suitability Assessment: &te Passed Sitc Failed: Additional Testing Needed(Y%N) Yr` Original: Public Health Division Observation Hole Data To Be Completed on Back --------- - ***If percolation test is to be conducted within 100' of wetland,you must first notl ify the , Barnstable Conselrvation Division'at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC I DEEP-OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil (USDA) (Mussel[) Mottling (Structure,Stones,Boulders. vel 4 3 10it r Depth from DEEP OBSERVATION HOLE LOG Hole# Soil Horizon Soil Texture Soil Color Surface(in) (USDA) Soil er (Munsell) Mottling (Structure,Stones,Boulders. ons' en % 5'L 1 D 1 t� I , A, w i� L4 `1.► . DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Surface(in.) Soil Color. Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C i, te vl DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Consi to 1 i Flood Insurance Rate Ma Above 500 year flood boundary No_ Yes Within 500 year boundary No es ' Within 100 year flood boundary No . es Depth of Naturally Occurrine Pervious Material Does at le ast four feet of na turally occurring erv'Y g p to s ma rial exist in all areas observed throw out the area proposed for the soil absorption s s ugh out Y tem? � If not ,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with .the required training,experti a and a perience described in�10 CMR 15.017. Signature Date-® Q:%$EPTICIPBRCFORM.DOC - ply t/ DATE. - 9/19/96...:_.. PROPERTY ADDRESS:_�,*1.5`7iiiiiper' Road' [RECEOVE® Centerville,Mass SEP 4 1996 - LT DCPl: - - TOM OF BARNSTABLE On the above date, I inspected the septic system at the above. Address. This system consists of the following: 1 . 1-61 x8 l, block: cesspool.' Based on my Ins.,. ction, i certify the following conditions: 1 This.. is not a title ,five. sepiia:.-syste.m.. 2. This is a 33 year' old sewage system. 3. Both. houselines rooted and dipped: L,.. House has. been used seasonally. 5.-. Cesspool has 30 of water. Sewage is 319'° below the invert pipe: Cesspool' -has never seen water any higher. SIG NATUR": • I Name J P Macomber Jr� Company: J. P_Macomber & Son_Inc Address _$-A�_-6b__ __ _ Cente�rvi11,e Mass : 0.2,632 Phone:---548�7-Sa.3338----- - f THIS CERTIFICATION, DOES NOT CONSTITUTE A GUARANTY OR WARRANTY CP.�.MACOMBER & SON, INC. nks-Csupools-Leachflelds Pumped & InsUlled own Sewer Connections6' Centerville, MA 02632-0066 775-3338 775-6412 U Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllllam F.Weld Governor Trudy Coxe Aryeo Paul Cellucci 8-0tar1' U.Gmvmor David B.Struhs Cormrissiorwr • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddreas: 55' Juniper Road' Centerville,Mass Address of Owner. Date of Inspection: 9/19/9 6 (If different) Name of Inspector. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 _. Fails G Inspector's Signature: The system Inspectors submit a copy of this inspection report to the Approving Authority 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 report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner,nnd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: --L�! 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",exp lain wily not) "VV6 The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exflltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 i, Printed on Recycled Paper � • r R,% �- xe�,,'�t,t�5 xi��.`•>< � "`a ,nyb•sNy IC! 1 .r� � ��kw _ . d {t _d SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM '- PART A CERTIFICATION(ooatLsued) PropertyAddrase 55 Jur �B.r hRoad`<Centeruille,Mas'sJ: Owners tr `...porethea s,R17Z7 ky f;k r4 t a Date of Inipbotioas 6 •, 1 f �� B)SYSTEM,CONDITIONALLY PA99E8(continued) .P't� Sewage backup-di breekst or hh,static water level observed in thi distribution boot is due to broken or obstructed I s or dus to a broken;settled or`uaevett'distributioa bas Ths P.Pe( ) Health). P�L>sPectioA if(With approval of the Board of �__ broken pips(s)iva replaced ' bos ii`3svelled or rep]aosd - � C �'� 4 7 �"i� �sx;� ��.'rvv*E J.,L{`B 14y y y +• .i _ r T�sy'ste required PR fhbfou>;times a year dw to b:+okan or obstructed i (s) The S 4. n,v. p Pe system will ias_pectioa if(with approval ot, r Board {�ealth) `,^^ J - p°°''' L°�� �91 �l'2Zk. Y� t �tii + �+ r �' •�-broke>}yp (s��e replaced obstruction is sesiwvad CJ FURTHER EVALUATION IS 'REQUIRED -Y�THEJBOARD OF HEALTH: .. _ AA Conditions List{VfYL:a ('4�,(y �•�''Q 1 fs}\1 y t r ,' ) 4_. '' - - ssquira!father avaluatson by thes8oaid of Health in sides to determine if the system ie failing to protect the public healt}s,safety aad tl�e anvL+oament. ' ,<' F�" x ,, r�l�Fh���{' I) SYSTEM WILI,PASS UNLESS BOARD OF HEALTH DETERMIPIF,q THAT THE SYSTEM IS'NOT FUNCTIONING IN MANNER.WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRUNMElM �Q Cesspool or envy is enthL►b0 feet of a surface water. Cesspool or privy is withLt 60 feet of a boidosing vep fated Wetland on a salt marsh, Z). SYSTEM WILL FAIL"UNI.E93 THE BOARD OF BE4LTH(AND.PUBLIC WATER SUPPLIER,IF APPROPRIATE) aD�E•PERMINE9 THAyT��T�H�pE S*YfS�T�E�}M}�I3 FZ,INCTIONING IN A MANNER THAT PROTECT THE PUBLIC BEAI,TH AND t7AC G lE iLi�t•+i01�NNM\i i� f lF"tF#J Sr 4 •q„i' r�'... • ti'� i$ r .�7 J y - �b Ths systesu has a septic tasilc and soil absorption system and is within°100 feet to a surface water su t `sxa�n s o f PPLY or tributary,to a surface water nPP� ,�Q•b The rystea►°hat a septic Ian]c sad soil aboorptwn rystem and is within a Zone I of a public water supply well, ,BLS The system has a septic tank soil absorptwn iYetem and,is within b0 feet'of a`priv$ta water supply well. The system has aseptic fault sad roll absorption system and is leas than 100 feet but:b0 feet or snore from a stunts water rgania c?mpounds'In'dicates that'the wall i .free Supply wev,'unless a well water aaa�ysis for cohlorai bacteria and volatile o from.Pollution from,that fa�ility sad the preaenoe of ammonis nitrogen and nitrate nitrogen is equal to.or less than 6 ppm. OTHER (revised 11/03/95): - 2` r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) propertyAddreas; , ,Tuniper Road Centerville,Mass'. , Owner. Derre-thea 'Ri iz i-e- Date of Inspection: 9/19/9 6 DI SYSTEM FAILS: V I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The baiii for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of eMuent to the surface ofthe ground or surface waters due to an overloaded or clogged SAS or Cesspool. ,vote Static liquid level in the distribution box above outlet invert duo to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 14 day flow. ,).0 Required pumping more than-4 times in the last year L10T due to clogged or obstructed pipe($). Number of times pumped 7 Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. t Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. djo Any portion of a.cesspool or privy is within a Zone'I of a public well. Any portion of a cesspool or pnvy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 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(Imp System)and the system is a significant threat to public health"safety and the environment because one or more of the following conditions exist: J4 ' the system is within 400 feet of a surface drinking water supply the system Is within 200 feat 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) ;<< The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Auther information.. (revised.11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PmPer'Address: 55 Juniper Road. C_enterville,Mass. Owner. Dore t.hea° Ai zi.,: Date of inspection: 9/19/9 6 Check if the following have been done: „�umping information was requested of the owne&,p=pant,and Board of Health. lone 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 iaspeetion. s OAs built plans have been obtained and examined Note if they are not available with N/A .ZThe facility or dwelling wad 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, ZAll system components,-Wduding the Soil Absorption System,have been located on the site. A NAIP,The septic manholes were uncovered,opened,,and the interior of the septic tank was inspected for condition of bellies or tees,material of construction,dimensions,depth of liquid;depth o m. f sludge,depth of scu ,1The 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 mainte g P Pe nauce of Sub- urface Disposal System. Sec ommendations 1 .The houselines should be repaced. Thel=present houselines are Orangeburg pipe,. Lines. are badly dippedig and rooted. 2. The single ce,aspool is in good condition and will sirfice as . a seasonal home: 3., For a year round' house` or useage i would recommend a new title five septic system, (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreas: 56 Juniper Road, Centerville,Mass.. Owner,. I Date of Iabpoutiou 7/ ga :Riz.z FLOW CONDITIONS RESIDENTIAIy Design flow:Q.gall r di�'y • Number of bedrooms: 01 Number of current residents: Garbage grinder(yes or no):AD Laundry connected to system Syw or no): � Seasonal use(yes or no):, � Water meter readings,if available: +, . J! , �0-4s Ae.* dd Last �-�T date of occupancy: Z COMMERCIAL/INDUSTRIAL Type of establishment: Design flow: Ions/day Grease trap present: (yes or no), .,1110 Industrial Waste Holding Tank present: (yea or no)AL/4 Non-sanitary waste discharged to the Title 5 system: (yes or no)A�4 Water meter readings, if available:___104 Last date of occupancy:_ /U OTIIER:(Describe) 1 Last date of occupancy: _ GENERAL INFORMATION PUMPING RECO S and sovu of informatiop:` System pumped as part of inspection: (yes or no)_ If yes,volume putuped:4)�._gaBo u . V . Reason for pumping: TYPE;OF SYSTEM j'SePtic taD-Vdistribution box/soil absorption system 1Z Single cecapool _WIN Overflow cesspool .AJb, Privy Shared system(yes or no) (if yes, attach previous inspection Other(explain) records,if any) —!� APP XI TE AGE of all components, date iaatalled(if known)and source of information:,ip sewage odors detected when arriving at the site: (yes or no) J, (revised 11/03/95) 6 UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) PropertyAddress: 5`- Juniper Road Centerville,Mass. Owner: a6rk;u R 9Z1 • ,t: Date of Inspection:g j19/96 SEPTIC TANK: A0we— (locate on site plan) Depth below grade:/(L/� aterial of construction:VAoncrele _metal _FRP other(explain) imensions: Judge depth: - �� ---��--' istance from top of sludge to bottom of outlet tee or cum thickness:_ istance from top of scum to top of outlet tee or baffle:—" istance from bottom of scum to bottom of outlet tee or baffle._ omments: recommendation for pumping, condition of itilet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural �rity, evidence of leakage, etc.) N C:.1,g REASE TRAP. (Cc1lr Gn sii3 ;;i�.,rO.� epth below grade:,' aterial of constr,-66n;V4 0,,-r?t _metal __FRP _'otht:;(uxplain) lmens ions: � cum thickness:___•/u}� istance from top vi scum to tep of outlet tee or baffle:_A)A istance from bottom nl <(-„m In bollom of outlet we or 611iv! Aj omments: e;ommc' i0n for f: (i�: i a; .. UUJ.. ., of bafK:: Jlh of ,ul o u d level in relation . to nty, evi nce of leakage, et &4 e evised 8/1S/95) a 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 5c5 Juniper Road Centerville,Mass . Owner. D`O•rP+.Ye+a .R .MZ.i :. ;x`.� Date of Inspection: 9/1 9/9 6 TIGHT OR HOLDING TANK446IK-�- (locate on site plan) e Depth below grade: ' Material of constnu U-4-1400ncrete_metal_FRP_other(explain) AM AM Dimensions: 411A Capacity: cus Design flow: Vf ons/day ! Alarm level: _ Comments: j (condition of inlet tee,condition of alarm and float switches, etc.) i { i DISTRIBUTION BOMAA� (Je— (locate on site plan) Depth of liquid level above outlet invert: Comments: } (note ' bevel and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) 5'/Gk-f i PUMP CHAMBE :-Y2 (locate on site plan) Pumps in wor"orden(yes or no)4 ±,. Comments: (a ndition of pump chambqr,condition of.pumps and a purtenances,etc.) (revised 11/03/95) 7 1 % ,. i D,i •sy, f\4.ii i. r 1 r, -F n f r, T ; „_.. r' �,.1,1,,�.��.:6e_.—:,..,�"",-"I.!�,.I1,.1)'.'�.*�,.I,m.�,-p�::--.11,,�,r,","�,,,I l-..*:-)I,.I"­.I��.b�.""..,�I 4..,.'.I"..,.,1­�,�,,,:"�,.,..L�.,,;-'.,. i- a'. Y , f ��r "t�xrr`s1. „`v.* s rCx} a vt;sw r ;'S 1'Y N 'r� }�.l! 't'�Y fih V �r� V.C*Y ;�4 }\ �`� N .,.,A-..b,.q_.I,I b.�,..y,,.­g..I..I..Lq,I�,,�­I.I��p..�...I..I.,L.�I.-.,-II-.-;...e,�.:%.4.,...I�.'�-.I.4,,I..,...,.r,I1,:.-�,.,..:-I....�,�-I.�,.�b­�'�.,.:Ir q....,..I..,.I"'.1-.,�I:��r,�.,-..-�,�.I t.�..".�I�.1 I1��.,-:...,.Ib-,,.V;......I....l"%1,'­"I�1-.��-,��..-:,..�1e..:Q�"..�-�',.I--,eI I L..-.,.��t.I 1.-.I,.,.4.I I.,�.I.'.:.IL..�..-I......,'^...,:I I..-A:..aII i�.Ir�r.''.�.I..�.....f.I.�.I),.I I:,.I�10.A.1I.,II.-.."-.j�.I.'..b..'9-,­.II,I_I,r,.I..�rr,II-...l.Lr-o�i.:..:-I./.—..I I%�1q.:I�...I".,­ �',-.1t,;,-,.�.�-,���.,,�,"I�",.��'�,-�,.�z,,.,­1'I".*�I e-;.,­.,"-.",,�.n..;i�,�I.f1'.��-�.;:---:.,,�,_�...,�-t�.:,,:-�1�­i-1.o­,�-�.-�,,I:",'�_��L-7..z�*-,;:---,.�,_�.--:I,i'�""r'.�-�-.....I.,.,,.;�..,_.�,q",`,,1��',.,�.,-I,:-.,I,�,1—-",,'�I,z,,,,;.�..,,�,,,�-,',�1L_.�-.,:;r,,�..IlT�i,��.,7.:�,�--��,,"�,--U�",;.'I"-.�-;�-_�--, .,-,-,��,�,,,,:.-1.i�,,-.,-:I�:�L I,.,,,�_"�,..-,,�-.,.b.,L".�,�.,'.:,.,�,,..r�:',.l.��,I���4.p-�.-.­�,,�,,_,;�,,--":r�,,.b-..,,,��,�'r,..,'r..,r....�1�,",.,!�­,,-..'.,.,:,,,z�-..b,...�.,�,:....,,:b,,'.,,.L,,",.:,',,.-.,,.,.­.:`,:.,,.�,?,.,,:,-...;,,.s�.:'�.�,:I--:,'. --�..`�I,.,,,,.�,,,'-:'.L­kr.",,.�;-'.�;..-.,:�,,.;,�L...,,�",i,:.,­,,., '-��",.'-,,,�.:,-_.,;',,�;11�-­.,.,.,,�.�, ..,.��-...,a,.,,.�I�:.�,..�.:-.. .,I,. _,1I,"�,,1­..,",.".,-I;�:,-I.,I.,, • tt"" z 3 ti!f r1'x �, t t k 45 .1 W \ tj:. 'x1a , e74 t: '!. .:i f 4 h ,� t '> riK�4: r"{1 S Jti/k 24,y#' 15 Y2+ '�.A! ? , f',. t Z'�'f 17�•ll l k, , �t , i'f4 ,, . . --."��-'�.:1?.,q�,,.',:.,--,_".'',,,,��I.,_.:,L..-1,I�,.,�i,,'..' *�r''I-,v,-�'_,��,.��,I,�,!,�.er�,I-..�f..*b"--,� "�M�,,,Lb.�­,_:"'"1_,,qI.,,:�,-�.,,,.�:LL,:" ":.�.!,_',::,,*-,!�:.��-,_*,,II:'.'�.,,.,'�-..'".�,,�IL, ',_.,.,,',,,:, .,�,,c,I4 --'I�,,`-�� - _ tt.. . .. - .i .1.... . -,,"",,.�;:,�)i� ,,., v t.'u31JFFACE 9EWAOE DISPOSAL SYSTEM INSPECT104 b'!>IIIrI ,` i F Si, 1 PART C _ � ,L i ,�,_ Z. ,,�'­.'I 1. SYSTEM INFOIi11tATI0N(oontInuod) .. t Al `2 '.t. .f, tt. %, y , y Property .:ter 5F'S Juz�i�er 'R;Q.ad�=;C:entervill:e,Maap• 1 pt` 2 , Y a f •owner pa-'st sal, t n H • t•�` . fi .g, {P t r '� i,4 �_.. k n�, »d ,t a� h�r'+ryY>•f"'G>1 'I)[' ! � tare DstO Ot aY/ tlilii: a k ; 'k sr t ' �Y,d M a g t ti SOIL ABSORPTION SYSTEM(SAS) � ~ ' . (locate on site plan,if possible;excavation not required,but mey be approximated by non-intrusive methods) t . u not determined to be present,explain . . • . ,. :..., I E 3e8ChiIIg pits number �' ' s 1 fvr ! , n yL , k v. ',1 A T fs f ",� !'?. i e .7. ? �h' 3 rr =° , t y AY a / f leacl:izsg chambers,`number. ©..,r , i o , f �7 ' y 3 r 7 'o�'!""3 6"'!w��3113mber�.fl ^ i t f i ,S leBChin$trenchc+s,n . , . r,length J Leaching fields,number;dimensions rRu ' owrIIoar cesspool,number, ,`a , ; Comments:(note 004tion of :1,atg:�of , licY failure,`level of pond:ag,oonditaoa of vegetad6u,ete) r . , ,. ,., M Fp I i.S2 ••+t CEMPOO f � . I - . , . I �,I 1, I . . I . . .- I . I ;�,....�-.%.I I-�I,.,.....�.­...�I,..I—b�,.,Iq�I�I....-"....LI IL....:.,Ir...,;,,b.,q.,-,..I L,-.I r I.�,.-.r;I.,.I......I I-.:-�11 Ib.�.�.�.I.I...,,1 I.,-:,.,..�1,......-.I...-�.,I.L.1...-.-.....,��.;,�I,..,...�...I-,..,�L.:,-..�I,�..I:.r..I,.L...II.. ryJ _ SS3 F +. a a. Y.Yy ' 7 , y.. t t { 1 f 4 \ 5! ). t i (locate on site plea) . . ( r s t r ir. °r r. 1 Number and conf�gutotIOa T % Depth-top of liquid to inlet vet: i Depth of solids lover. Depth of scum layer. P . Dimensions of cMspoo1: Ddaterials of oouatruction: Indicatiouof;mundwater: • "AJ�;� o omf Cesspool 3 Off water table See page 8A t; inflow(ooss must be pumped ae of pection) ';/ '' t 4"� .;,. w �`C' '.' j'S:n . „li:: 4"Sr ir�r� Y' d r;;f'Ff ,, r, � :t Sc<- t t , a "':.'. .;'.r ��✓ "*..•12,rl fF r..,' > \rr:.rr �s�";.,,`y^5,i .•�! G e; ,rr 5"rr';,a iH i •} r`Y.v F Comments.(note condition of soil,signs of hyciruac failure,level of poadia&oonditioa otwgetation,etc.)• • Loamy Sand to Medium coarse:, nand;+ No; by rauli.c".' allure•. or.='pondi'ng; . All_Ve station is normal: No reAaira'needed at­the" present ma Y d a .. y \ ! 1 } PItIVYt �ONC r. , (locale on site plan) . . < k 4 MaterIaL of oonstructioa �l�l DimeIIiioaf tom,__ Depth otsokds: M V tqk f r,' i,:� , J + .to-j j ' z -_k t\ y e Co ts:(note coadi�of on;signs of hydraulic failure,level of pondin&condition-otwgetation,etc.) . ,.. . a i ­, �. , (revised 11/03/95) g . ,.. �. P ;.: ., -, ,C�':�,�:►_J T���r"Igo c.�5 �Z-is; "%' ", i ' n 6-1 rv. w �,-,.wr lit' 1, .6 cc,�c V �' ,_ .i'CP6 •�' ` N l' ���,� T27�/ifF•!J'Ni�l.�)'1�lif /6.O ' - a ui�a/n/G S ETBAGAc .2EQU/,2e-MEa/T� SC.4 L E J _ ,3 U . - O_ F2ONT F::. P.�eopa SE.n SEPTIC yS TEM CONS T2 UCT/ON SNAc1. CorvFo2M To M,g55. OES/GN FLOtt/ 330 . GAL. p,4Y ENgr-1!✓QOrVMENTA1, �COOE T/TLL Y Z-/-7-7 -e//1.?C;E LEACA/ ,2A7E M/N.I//VGN �'EQU(,2G-17 LE�16'�,4 � �r'Y TOP OF //�AGTH .2EGCJLAT/ONS P2 O�0 . A MANHOLE CO✓E,0 Tb.' EXTEND TO/ /MpEQ,V/0US CoVee W/ TN r 'O A/a/A/ / OF. 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