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Home My WebLink About0058 KATHERINE ROAD - Health 58 Katherine Road A- 228—145 Centerville 1 j U L. 1. :21:10'T 03 :07 PM JCENGINEERING 508 273 0367 P. 02 ammonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Katherine Rd. !property Address Marion Wriarty ri.�qnired For d,llall� .�.enterville .............. ........... . .................... MA 02632 7/6/2007 ^31ty/Town State Zip...1.1 Code., Date of Inspecti.o-n............ ................... Inspection results must be submitted on this form, Inspection forms may not be altered In airy wily, 1111,porhvv;V hen flll,f,gIulj fon!' A. General Information lit oil 1,1111;,irnp, -.tql, Uti; w1l),t�111 i Rb 1 Inspector: north L. kffY to rY0Rl',o0L I' C wiA)r cj() j(,t CH C OL L John L. Churchill Jr., P.E. jf� ulim�the retuir, ............... ........................ . .............. ........... kny. Name of Inspector NO 4180 1q.EqgAl lnjg.I.nc. Company Name ......- _�_._ 2854 Cranberry ----------- - --------------- ... .............. Company Address East Wareham Ma. 02538 ...................... - ...... ......... cilyrrown State Zip Code #41807 6 ...............................- 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 axis 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 16.341) of Title 5(310 CHAR 15.000).The system: Passes ❑ Conditionally Passes 7 Fails Needs Further Evaluation by the Local Approving Authority 7/9/2007 ............................ actor's Signature Date /The system inspector shall submit a copy of this inspection report to the Approving Authority i,'Doard of Health or DEP)within 30 days of completing this inspection. If the system is a shared systill'i or has a design flow of 10,000 gpd or greater, the Inspector and the system owner shall submiii the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, If applicable, and the approving authority. IN I Ire"ORThis report only describes conditions at the time of inspection and under the condlItionv of use at that time.This Inspection does not address how the system will perform In the future under the some or different conditions of use. ALSO '7- 14A,16 CO"-*IC-f60 WAN Y)ALL Y W-' 197AF-5 ACP ANO i ct2;le . Orbs H is 1z IE co Ph c-",/ 'A1'LVR&-7'14 A ( r7 LU;A-L PAS-5 , ;.:l I'l ti I,Ino Y*i ov If I W I,•08M, A 0 ion Fffrry Subsurfece Sewipe MBPORal SWOM I P1196 9 Of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is Centerville MA 02632 7/6/2007 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the -N OFvtis_ computer,use y only the tab key 1. Inspector: o JOHN L. to move your John L. Churchill Jr., P.E. CHURCHILL m cursor-do not Name of Inspector JR CM L use the return No. 41607 key. JC Engineering Inc. Company Name 2854 Cranberry Highway Company Address East Wareham Ma. 02538 City(Town State Zip Code (508) 273-0377 #41807 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 maimtenanc-of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15:340$`f Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fall"s� e S21 crCD ❑ Needs Further Evaluation by th ocal Approving Authority ' '= v> ry �� 7/9/2007 �' I ctor's Signature Date system inspector all 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. 58 katherineTitlevinspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. City(T'own State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The Leaching Pit is dry due to lack of use, there appears to be a dark staining above the invert into pit, which is evidence of sewerage over the inlet, however during this inspection there is no backing up of sewerage into any components, therefore the system passes based on no failure criteria observed. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 58 katherineTitlevinspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Katherine Rd. M Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 58 katherineTitlevinspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 58 katherineTitleVlnspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 58 katherineTitleVlnspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is Centerville MA 02632 7/6/2007 required for every page. Cityrrown 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)] 58 katherineTitleVlnspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2005: 265 GPD g ( y g (gpd)): 2006: 60 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: unknown 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: Last date of occupancy/use: Date Other(describe): 58 katherineTitlevinspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 58 katherineTillevinspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): ' Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage. 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: 8'6"x4'10"x57- Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? measured. 58 katherineTitleVlnspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown 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.): Pump tank every 2-3 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound, tank was empty due to pumping last month by Capewide Enterprises, LLC. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 58 katherineTitlevinspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 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.): Box is level. Box has one lateral. Slight signs of solids carryover. Some scum in outlet pipe to leaching pit.lnstalled Zabel filter in outlet end of tank. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 58 katherineTitlevinspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil. Leaching pit was dry at time of inspection. Signs of staining above inlet invert, indicating that the pit has backed up in the past. I 58 katherineTitlevinspJC.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 58 kalherineTillevinspJC.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 5g I.f11cN1�16 P� NL 1 14C 2- loco � SEPC�t 'iAN1F �9 0 DeS1Q1GU111,6" sow sw�+ac. =HE'S n.T.9. Nc 1 14L z- 14 Z 2Z� AJ-4 3 ZO 54 58 katherineTitlevinspJC.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville MA 02632 7/6/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: Bottom of pit 10' down 40'to water feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty & Miller Model 12/16/94 ground water elevations.Used:USGS Observation well data June 1992.Used:Technical bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. 58 katherineTitlevinspJC.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1 '4 Flynn, Judith From: McKean, Thomas Sent: Monday, July 16, 2007 1:47 PM To: Flynn, Judith Subject: CORRECTION -----Original Message----- From: McKean,Thomas Sent: Monday,July 16,2007 1:37 PM To: Flynn,Judith Subject: This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the disposal works construction permit. 1 Flynn, Judith From: McKean, Thomas Sent: Monday, July 16, 2007 1:37 PM To: Flynn, Judith This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the disposal works construction permit. 1 L Wadlington, Ellen From: McKean, Thomas Sent: Friday, July 13, 2007 3:12 PM To: Heath DeptMailbox Subject: 58 Katherine Road/Three Septic System Inspections FYI to those who have been involved in this and to those who may be interested - Three septic system inspections conducted at 58 Katherine Road by James Ford, Robert Paolini, and John Churchill, P.E.. First Mr. Ford submitted a report indicating that the system had failed,then the other two indicated that the system had passed. The third inspector sought the advise of DEP before submitting the passing report. His report includes his observations of the staining in the leaching pit which indicated that there may have been a back-up at one time. I talked to Brian Dudley of DEP this afternoon about this case. Mr. Dudley informed me that technically this system does pass. The observation of dried sewage staining at or above the inlet invert to the leaching pit and on the inlet pipe itself does not meet any of the failure criteria in Title 5. However, Mr. Dudley stated "there appears to be a question regarding how the system would operate under operating conditions." 1 1 Town of Barnstable OF tHE 1p� do Regulatory Services .AxxSIAB Thomas-F. Geiler,Director 9� MASS. •• Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 June 25, 2007 Ms. Marion Mariarty 58 Katherine Road Centerville, MA 02632. ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5 The septic system located at 58 Katherine Drive, Centerville, MA was last inspected on May 20, 2007,by James M Ford, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The leaching pit is in failure Because questions were raised about the accuracy of this report, a second inspection was done by another inspector and the system was passed. Unfortunately questions were still raised on this matter and yet a third inspection was conducted by the original inspector, the second inspector, and the Head of the Health Department(Mr. McKean); it was the consensus of all three that the leach pit was in need of repair. You have subsequently had a telephone conversation with Mr. McKean pertaining to this matter; as result of that conversation you were advised as to your options. You were given 60 days.to have the failed system repaired; under the circumstances and because the house is unoccupied at this time we will extend this requirement to 90 days from the date of the receipt of this letter. We would like to offer our apologies for the inconvenience this has caused you in your efforts to sell this property. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health *This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the disposal works construction permit. I TOWN OF BARNS/TABLE LOCATION .�q Ki 044�r/i7`� ^?G1 SEWAGE # VILLAGE Of//6e r P-"'A I^ e. ASSESSOR'S MAP & LOT —IA15� DWFTA&bEtLS NAME&PHONE NO. �CA,7 N u rCh 1.4 J. : SEPTIC TANK CAPACITYa LEACHING FACILITY: (type) NO. OF BEDROOMS —23 0,31A.eP 711316-7 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Q DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 58 Katherine Road Centerville, MA 02632 Owner's Name:, Marion Mariartv3�� Owner's Address: Date of Inspection: May 31, 2007 Name of Inspector: (Please Print) James M. Ford . Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 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* { c_ ,w' c Passes - = � Conditionally Passes . Needs Further Evaluation by the Local Approving Al ity 70 . ✓ F is :a: � c;r —t Inspector's Signature: Date: June 12007 c The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board f Health or DEP)within 30 days of complett g this inspection.. If the system is a shared system of 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within'50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow,(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: proximately 1994 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Katherine Road Centerville,AM Owner: Marion Moriarty Date of Inspection: May 31, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron —40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 ag l• Sludge depth: - Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 1" Distance from top of scum to top of outlet tee.or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). The tees were present. The liquid level was just below the outlet P pe. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 TIGHT or HOLDING TANK: None (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/day. Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above 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.): The D-box was normal there were no solids present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000 gaL). leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit was dry and the scum line was above the inlet pipe up to the top o the pit. The pit is in failure. The bottom to grade was 8.5' CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 j I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LA AC 4 � s ' 3 Q ' 4/ � aay� 3 ao S1 10 t, Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Katherine Road Centerville, MA Owner: Marion Moriarty Date of Inspection: May 31, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +1- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 35'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and failed as of the date of inspection..This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report andlor any components of the septic system which have not been located and inspected. 11 Commonwealth of Massachusetts Title 5 Official Ins?plect-i,onlform Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.w 58 Katherine Rd. SV•'` Property Address Marion Moriarty ____._------ Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information -39�-When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name !� P.O.Box 763 Company Address Centerville Ma. 02632 rerun city/Town State Zip Code (508)428-4028 Telephone Number License Number B. Certification 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 Ev luation by the Local Approving Authority 6/7/2007 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. l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every 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: ® 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or,not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,. 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection. B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: 1 ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 i Commonwealth of Massachusetts W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments M , 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town, State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ' ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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. t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑' The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information 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)] l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official .lnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® .No 000 ,:107 Water meter readings, if available (last 2 years usage (gpd)): 2002005:10700 Sump pump? ❑ Yes ❑ No Last date of occupancy: unknown 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: Last date of occupancy/use: Date Other(describe): t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured Reason for pumping: maintenance i Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site.plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years. Is age confirmed by a Certificate of Compliance? (attach,a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'10"x57' Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank pumed at inspection. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet, Material of construction:. ❑ concrete ❑ metal ❑ fiberglass ❑,polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons •Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one Iateral.Slight signs of solids carryover.Some scum in outlet pipe to leaching pit.Installed Zabel filter in outlet end of tank. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): / Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer -Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner Owner's Name information is required for Centerville . Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters,the building. t { css WHOA aiva OIqS_S,e s d � I ...ON t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Katherine Rd. Property Address Marion Moriarty Owner' Owner's Name information is required for Centerville Ma. 02632 6/7/2007 every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Site Exam: i ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to..ground water: Bottom of pit 10' down 40'to water feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller Model 12/16/94 ground water elevations.Used:USGS Observation well data June 1992.Used:Technical bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. i t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 tNE Town of Barnstable OF tp� Regulatory Services saiuvsrAsLa Thomas F. Geiler, Director Q MASS 9`�Ar�16,39. � Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. VET ✓ � ';. �-.,�..- �" -e � , �! i..w.,:w.a,��'�''�y+'«mextn°�R'9av' 'H? '�yi. °moo Town of Barnstable. --,--.,__,_ f 'r.,, ;W : ,, y ,�..,`� •� ? •`�a,�.,�.,.�= ..""'ate,�..,�• Public Health Division ^�.. • .ABNST,IB �. 'fi3.a t tl s x; •. ».. 200 Main Street Hyannis;AMA 02601 F7YNEY ELOVVF5 • 02 1A $ 05.210 k • 0004606238 JUL25 2007` MAILED FROM ZIP CODE 02601 - 4 1 Ms Marion Moriaty 58 Katherine Rd. 4 -Centerville, MA 02632 FORWARD TIME EXP RTN TO SEND MORMART'v" MARION E 71 STAf3I"tOARD OR UNIT 240 TIVERTON R1 0 878--427;3 j RETURN TO SUNDER -0280104002 ' .111,1, lilIlhill,,,,1,1111„11.1I,]}1,,:,,l,lll,,,ll)Mkil,=i S" i % \\ \` tr I tl lii 11 I II Iil I { ( I ill ti I I I I Ili Illlll ,,, Town of Barnstable OF THE rp� Regulatory Services snxrrsrnsz a Thomas F. Geiler,Director b 9 r Public Health Division ArFp��a Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. fl_IL. 1.e: -2 30T 03 :07 PM JCENGINEERING S0E 273 0367 P. 02 Commonwealth of Massachusetts Title 5 Official Inspection Form subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Katherine Rd. _._ .. _..._....._._....__......_....._.._. ... nTCjidy Address Viarion Moriarty :hwner'a Name Irl.'::Thet:�n it ;;entarville MA 02632 7/6/2007 _ _ ntl:.lired PtJI•e?.rli1lr -----•-_.._.—..-----.._.._._........_......_._..----_..... . _.._--------•• ---_......__..... ._....,,...._....., . W11Z;3 �ItyrroiNn State Zip Code Date of Inspection _ Inspection results must be submitted on this form. Inspection forms may not be altered In a!ay WRY, hnrartlrr::ttt1®1! A. General OI1fOY111at8®P1 _W..__._.--_--- ---.----------- --•-•-- C[t!.18 G.[nlfl.b.91, w,+ orili•inii I ib }• Inspector: JOHN 1- ko.)to MIYA 011' CHURCh+IIl cu';;rtr• (1) vr.t of Inspector No 41807 Jtt d �iohn L_Churchill JrJ P:E---- - -..._............. .. ...... -- — ---- kL�iieoy cu�� __...... ... the gin' me ray. Na ,��-..a. ,JC Englneerl.n�...Inc._.._...._..._._........... Company Name -'-- _ 2854 Cranberry hwa .._._..—._...____ - _ 1 Company Address !A!iI East Wareham Ma. 02538 Cayrrown State Zip Code 503 273-0377 #41807 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 v ais 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 16.3,41) of Title 5(310 CHAR 15.000).The system: z Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ;1 7/9/2007 actor's Signature ! - Date The system inspedtor shall submit a copy of this inspection report to the Approving Authority I;I:Ioard 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 submiil the report to the appropriate regional office of the DEP. The original should be sent to the systern ;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 condltlolnsi 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. L 5a z 14A IE Co w91`1c-14CO l�+Z/AN Y)ALC y a r' ��.s.� DEP' �� t)Pb^.,� is 2r"cor�c��rt r�'oN -7'14A r ri No X i A T /YI E D F I,,,S p'�, pN� 17 w, P�tPss !:a In ha7i i,v!nuoJ':•oaoa r' �I Tile OMici■ In9 a(ion Forrn 5ubaudece&■w■pe Die octal B ROM Pugs S of 15 TOWN OFnBAJRNSTABLE LOCATION b NAThy n L 1`C SEWAGE# l 9 `/ ✓ILII.AGE nT��r�� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. A al SEPTIC TANK CAPACITY LEACHING FACILITY.(type) ze) 01b NO.OF BEDROOMS 3. OWNER Or1AAlp PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) C Feet FURNISHED BY �C-A SPELT-Im _ f d J A n�lc a ;r 3 a 0 0 � y ► acv � aay� 3 no Sy No..... ......_ .. Finc....$....3 ...00.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �a $ � qS TOWN OF BARNSTABLE App tration for Dtopoottl Worth Towitrurtion rrrmtt Application is hereby made for a Permit to Construct ( ) or Repair ]�XX an Individual Sewage Disposal System at: 58 Katherine Road Centerville - ......._.. ............... ............•-••------••••----••-•-••••-••-••-•---•------•----•-•-•-••--•------•---••------....._. Location-Address or Lot No. gr artx---••...............•------......---•------•----•----•--•---------------- Owner Address ._J_..P_._Ma.c.ambe_r...Jr.-•...•--------••----•-----------•------•------------- ------------------------------•--•--•-•----•------•-•- Installer Address Type of Building Size Lot............................Sq. feet �-. Dwelling X-No. of Bedrooms---------------B_____-___________-___--____Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------.-_---------------------------- __-_-------------•--------------------------------------•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter-----........... Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------.-_- ------ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit--._________________ Depth to ground water..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ...................................... -----------•••-••••-••-•---•-•-•-•----------•••...•-----••-•-......................................................... 0 Description of Soil.............................................5a11d...&-•.GrC1:SLel..................................................................................... x U ---••-..._.....-•-••---•-•----•-•--•••••-•-•---------•-------------•------------•-•--•••••••-•----•-•-•------ -----•---------------...--------•-------------•-•••••-•--•-•-••--••---•-•------•-- UNature of Repairs or Alterations—Answer when applicable----------Qrnit---- 2ss-fool•s•.----Ins•tall..................... _1:1.0.0.0_._ga.11nn...tank---1_-.d.istr_ibutiD_n_..bDx.___l=100.0---ga11on...leia chi n.9.._P.i.-t__________________ Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e has been 'ssued by the board of health. -ti 8/2/94 Signed .. - .(�. . .----'-----.fit.... -- ........................ ............ . .................... Dace ApplicationApproved By --------- ------ -- ----- - - ------- - -----Q-..-... .- ...... ........... ................ --------------------------------------- Dare Application Disapproved for the following reaso s ---------------------- - ... _ ... . - -.-,-.......------------------------------ .- -- ---- --- -- Permit No. - ..... .... -- ------- -- --------------- Issued ...............ice .... ace TOWN OF BARNSTABLE q LOCATION Jr A A %l-Ifil !#G Xp SEWAGE # ( N VILLAGE C -f Al relf V/1- J-�'-ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. M /4 G om j5e f 5OAl SEPTIC TANK CAPACITY /. C LEACHING FACILITY:(type) �/ (size) /.0 O 0 NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: - �- `e( Lt z " DATECOMPLIANCE ISSUED: �\ r. VARIANCE GRANTED: Yes No 6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE `LEltiftratE of CDmplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by ... ...J...P..-Macomher....Jr,------------------------------------- ------------------------------------------------------..........._--------------------------------------------- i�taiier at --.......58 Katherine Road Centerville --------------- ---------- ----------- has been installed in accordance with the provisions of TITLFr of The tart yironmental Code as described in application for Disposal Works Construction Permit No. �� ..�0' '.."?...� .... dated ----------------------------------------------- the THE ISSUANCE OF THIS CERTIFICATE SHA LL NOT BE NSTRUEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------- r .. Inspector ....... --------------------- ---- --`-1-,4- ? - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE NO....................... FEE.........3 0.....O. y Disposal Mods Tuntrurttnn "rrmit J P.Macomber Jr. Permissionis hereby granted----- ------------------------------------------------------------------------------------------------------------------------------------ to Con rb uct ( ) or Repairr . X4 an Individual Sewage Disposal System � Katnerine R Street ! •� at No..................................................................................................................... shown on the application for Disposal Works Construct*on Permit No�-..►..............� /1 Dated.-------....(....�-------.-...--------.... A- ........................- ,------------------------------------------------------ L� Board of Health DATE......�- .........................................----=-•-----�--- - FORM 36508 HOBBS♦!WARREN,INC.,PUBLISHERS No................_....... Fis....$....30.00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I TOWN OF BARNSTABLE asJ Apphration for Di-nVniittl Works Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair gXX an Individual Sewage Disposal System at: 5$ Katherine Road Centerville Location-i\ddress or Lot No. Moriarty... ..-•----•.-•------ Owner Address ro. ...,7r-2-----------------------------------------•--------- --------•---------------------•-----•---------......-------------••--------.......------....-•---- �"� Installer � Address UType of Building Size Lot............................Sq. feet .-t Dwelling X—No. of Bedrooms...................A.---_.-__-..-.--_.__..___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building --------------------------_ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitv------------gallons Length---------------- Width.....----------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.....--............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.....---------......................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................-.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------------------------- ------------------------------------•---------•-.......-................................................................ 0 Description of Soil....................•........................Sand_&,,,Gravel x - - - - -------------------------------------•--------------------------------•-•------------- w UNature of Repairs or Alterations—Answer when applicable----------Omit_-_ces-s-pools .__ Instal]...................... _on___bo...I.-1000 .aal1.on_- leacY�ing..pit,, , Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e has been 'ssued by the board of health. Signed -''.'.. � .... ~' 8'/2/94 _ Date ,� '- ....... ---..................—. ........................................ Application Approved By ......, ,. I / V........... ..�: �% v1 /t.l Date Application Disapproved for the following reasoni `.................................................t--------------------------......----------------------------- ..........................._:,}..... .-------------......./"1./,,.A,,..----------------------..__........_................"------e -- Date........................ - --— ---'—`--..— — ..- 1.... ... .......:... Issued ..... � iPermit No. ...... ...."1..,....,1.....................- t` 1 vDate