Loading...
HomeMy WebLinkAbout0013 LAURA ROAD - Health 13 Laura Road Centerville P A = 251 113 i �I I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'r r� 13 Laura Road Property Address' r4 Rachel Holthouse r Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection :.t 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. Inspector Information (5 ,-S-q on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road r� Company Address Teaticket Ma. 02536 City/Town State Zip Code � 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-23-2019 rispector'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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 13 Laura Road v Property Address Rachel Holthouse Owner Owner's Name information is Centerville MA 02632 10/21/2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 4 bedroom home has a H-10 1000 gallon septic tank and a d-box feeding a leaching trench. At time of inspection there were no visible failure criteria found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts p. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V!% 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken i Ele pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary(cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 water supply well. [I ® Any portion of a cesspool or privy iswithin In 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply I ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In first 1/2 of 2019-49,000 gallons were used. In 2018-117,000 gallons used and in 2017-91,000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��, 13 Laura Road Property Address Rachel Holthouse Owner. Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: A new leaching was installed on 09-07-2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 21" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): water was flushed and it came freely t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): " Depth below grade: 21feet 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: H-10 1000 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form IQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .., 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: One 10.5 x 40 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form y�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 r - Commonwealth of Massachusetts �. Title 5 Official Inspection Form <le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately ID t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION f V a SEWAGE#/ Jt"— VILLAGE CAI .[_U��� ASSESSOR'S MAP&PARCEL Ali— INSTALLERS NAME&PHONE NO. _ 0 C-T— 14/—°1)59 SEPTIC TANK CAPACITY /vaO LEACHING FACILITY:(type) 3p Grp (size)/O-3 X 110 NO.OF BEDROOMS OWNER 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) 5 Feet FURNISHED BY I �32•.i p C p F.Z1.1, P° // I Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet 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: I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... ., 13 Laura Road Property Address Rachel Holthouse Owner Owner's Name information is required for every Centerville MA 02632 10/21/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included � 7 M D r S 1G1 S I P/✓j A)0 Mz� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION / �'.�-04/ SEWAGE# �- Z ErILLAGE �f1 !/N/7�i ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. CL 9/)/—`i 1 99 SEPTIC TANK CAPACITY /C.70 0 LEACHING FACILITY:(type) ;J®�yv (size)`O,S X 4VO NO.OF BEDROOMS q OWNER s PERMIT DATE: �f'—�f—O/� 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 f i , � � � ,� ':. �'� °��'� � �/• ,� 3�-� � � � L �-���� ,.�, . ���,�, ���`'� .ems/ P®'� No. 007 —3 l 2— Fee THE COMMONWEALTH OF MASSACHUSETTSf Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipphratton for �Dtgpogar i§pgtem Corgi.Otructtou Vermtt Application for a Permit to Construct( ) Repair(M/Upgrade( ) Abandon( ) ❑.Complete System U Individual Components Location Address or Lot No./3 ,.�L4R A Owner's Name,Address,and Tel.No. A/el Y-haw e Assessor'sMap/Parcel �� L/ L �l,Zt/G- ��-�+►te��r/�(J Installer's Name,Address,and Tel.No. /��T�`�-�JT Designer's Name,Address and Tel.No. 6ihl�Ia/Tt L!� Type of Building: Dwelling No.of Bedrooms Lot Size NO&S— sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) L�� gpd Design flow provided 4/0 gpd Plan Date LIJ�J` /7, A2,97 Number of sheets ® Revision Date '— Title !//t r S.4 P41 �q Size of Septic Tank eil� n i, ®CV 6 Type of S.A.S. Description of Soil �3 Nature of Repairs or Alterations(Answer when applicable) Z,CiCl/"+J Y— A � 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 BoAard of Health. Signed Date Application Approved by Date 7— O 7 Application Disapproved by: Date for the following reasons —•� Permit No. �®® / 3 �— Date Issued >7' / (� No. DO 31 �-- 4 Fee " COMMONWEALTH OF MASSACHUSETTS Entered in computer:ISHIE PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for �Digpozaf 6potem Construction Permit � Application for a Permit to Construct( ) Repair(Zupgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No./3 *G 4 Owner's Name,Address,and Tel.No: Assessor's Map/Parcel / / L Installer's Name,Address,and Tel.No. &21,U/11, Designer's Name,Address and Tel.No. Z�Iv✓ G.amw�dr �nl IV y• 5W1 Type of Building: 1 Dwelling No.of Bedrooms Lot Size /000&5- sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers'( ) ••.Cafeteria 4 Other Fixtures ; Design Flow(min.required) � gpd Design flow provided Y f gp& Plan Date w�)A /7, t /� �Cr/7 Number of sheets Revision Date Title %Ile r S,/t /G✓I /� L�vr, /� trYry /f, •a' .. Size of Septic Tank h7;(e)/,h a /� Oc&.., [a. C Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t„ . � r�ai•- ,,�jv(f•71 ° ,r4` t 4, ` Date last inspected: `) -�r� � Agreement: r` '°* "- -KKK. The undersigned agrees to ensure the construction and maintenance of the afore described''on-site sew e disposal system-,in_ accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operationNuntil a Certificate of Compliance has been issued by this Bo rd of Health. Signed � _ Date 9 Application Approved by t� Date 707 Application Disapproved by: Date for the following reasons i Permit No. O't Date Issued - 7' 0 7 , ♦ .- ... ...: ..- - -... _.--:,ram-� - ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( W1 Upgraded ( ) Abandoned( )by 1 /Al , A111/1 I, at /3 4Girirc 1, s 1- ,o rWillr has been constructed in accordance with the provisions of/Title /5 and the for Disposal System Construction Permit No. rdl-4O* 3'11-- dated Installer / a/�i�ldTl;. C,oyJr ► Designer / o/ #bedrooms Approved design ow 7�3 d � gP � The issuance of this permit al not str as a guarantee that the system will ,nc Rio as/((designe C Date Inspector ! l 8) A /C�✓ No. 9-00 - 32, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=i!9pozat *pztem Construction Permit Permission is hereby granted to Construct ( ) Repair ( �upgrade ( ) Abandon ( ) I System located at /3 `qua Tenn A7, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. 1 Provided: Construction must be completed within three years of the date of this e � - � Date � � Approved by� � FROM :down cape engineering inc FAX NO. :15083629880 Oct. 05 2007 07:24AN P1 Town of]Barnstable Regulatory Services 0SUMM Thomas R. Ceiler,Direetor Public Health Division Thomas McKean,Director 2.00 Main Street,Hysatxis, MA 02601 Office: 5O€-86?-4644 Pas; 506-790-63N ln%Wler& Designer*Certificabou Form Dater Swap Permit# r�20`2- 3 92- Assessors Map\Parcala`S/ t� pester: LA) V\ � E r r w-j�� Installer: Address; � a r �� Address: ;4 �• �0)C �� cn, GJ -7-O -7 J issued a pennil Lo ins a (date) (instalie-) septic system at �� ��.�"� based on a design dm,%,N n by (address) dated (dasi er) T cer.if! that the septic system referrenzeid above was installed substanvally according to the design,, which may include minor approved changes such as l=al relocation of the dis ribution box 2zdi r septic tank. _ i cerdfy true the septic system reference:, above was iu�ed v"nth major changes (i_e. greater than 10' lateral relocation of the SAS o- any vertical relocation of any component of the septic system) but in accordance with St2.te & L,oca) Regulations. Pian revision or certified as-built by dcsigner to TolloW. ARNE M OJA A fi er'5 Si gT:ature) CIVIL No. 307�2 10,NA- es�� e ' S ature) (.affix Designer`s Stamp Here) PLEASE REM ' TO BARNSTABLE PUBLIC HEA TH DMSION. CFR FICATI OF Co mpi' A'+CE WILL NOT .0 ISSUED UNTIL BOTH THIS FORM kND AS-BUILT CARD ARE RECEIVED BY TH)~BARNSTABLE PUBLIC 14E8LTN DIVISION. THANK YOU. Q:Ht21th/5cptic/Designer Cerilleation Form 3.26-04.doc i5 220• PiLparanon of flans.ana J2ectr sia!,a� , n u , r Tnd plans and specifications for every on-site system shall be prepared.as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not-design a. system designed to discharge more than 2,000 gallons per day Pursuant to 310 CMR 15.103. Any other agent of the owner.may prepare plans for he repait of a system.designed to discharge not more.than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are revicwdd by:a Massachusetts Registered Sanitarian and,approved by the.approving (2). .Evety:plan submitted for approval must be dated and bear the stamp and signature of .. : the designer, (3J Every plan for i new system or plan for the upgrade or expansion of an c_:stirig:system"' which requires a,variance to a property line setback, distance, must.-also reference'a plan which bears the stamp and signature of a Massachdsetts. Licensed Land Surveyor in accordance with M.Q.L. c: 112. § 81D; (4) Every plan for a system shall be of suitable seals(one inch =40 feet or fewer for plot plans nd one inch;=20 feet or fewer for details of system.camponenis). a,gd shall.include. : dee ( rtan of: the legal boundaries of the facility to be served: (b) the holder and location of any easements appurtenant to or which could impact the - : '.r• rem; _. _. . . (c) the locatiorr.of the all dwellings)or building(!;) existing and proposed on the facility d identifie,jri i of those to be served by the system; - - '(d) =•the`iueation of 6dstis g of proposed imperzi-aus-ar:ear, ineluotng:-driveways and king areas; -• . - (c) location and.dimen- on s of th'e systcm (including reserve area); Q- W . system dcsign calculations,including design daily sewage flow, septic tank capacity cd and pzoyidcd); soil absorption systcm capacity (required and provided); and ether system is designed for garbage grinder, - North arrow and existing and proposed contours; (h '.Iodation*and'log of deep•ob'scrvadon hole tests including the date of test, existing ado elevations marked on each test, and he narrtes of the representative of the ' a oving authority and soil evaluator, 1) location and results of percolation tests including the care of test and the names of SKI am of the approving authority and soil evaluator, . G) name and cc,Z3catiniti aumber--of the Soil-Evaluator of record; (k) location .of cvcry watcr supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies-a.-td gravel packed public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public water supply wells, and 3. within 130 feet of the proposed system,location I the case of private water supply wells; 1) location of any surface waters of the Commonwealth;-rivers, bcrdc=g--vegemted wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,'tributaries to surface water supplies,certified vernal pools,private water supplies or-suction lines, gravel packed-or tubular public water Supply wells, subsurface drains, leaching catch basins, or dry wells; and ;he location of any nitrogen n/.f�scn 'rive area identified'in 310 CIvLR I4F_215 witE is which portions of the proposed 0" stern are located. ( location of water lines and.ocher subsurface utilities on the facility; observed and adjusted ground-water elevation in the vicinity of the system; o) a complete profile of the systcm; ' (p) • note on the plan listing all variances to the provisions of 310 CMR 15.000 sought 'Y to onjunction with the Plan; q) . the location and,elevation of one bet:chmark.within 50 to 75 feet of the facility which is not si;bjcct to dislocation or lost,d z: g consa-uctich on the facility,' f� when dosing is'proposed, 'camplote design and'specification of the.dosing system �}/proposed including.but hot limited to dosing,chamber capacity (required and provided),' urnp curves and.specifications, number.of d'osizg cycles and depth per cycle; when a Rccirculatis,, Sand Filter or equivalent alternative technology is required or r osed, a complete plan and spcciflcadon for the systcm,including a hydraulic profile; a.locus plan,to show the, location of the{aciliry including the nearest existing scree:; the strect nLmbcr and lot number, if any, of Mitre facility, and, the materials of construction.and the specifications of the system. TOWN OF BARNSTABLE LOCATION 13 �'`�V�'4 1`� SEWAGE # VILLAGE CeAlitxv'At. ASSESSOR'S MAP & LOT C3LSI ' //3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Uw LEACHING FACILITY: (type) C2Ss10Uol (size) NO.OF BEDROOMS Y r)j BUILDER OR OWNER �V 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 leachi g facility) Feet Furnished by sp�,c bn �' FO/� f BAck A 13 O � TOWN OF BARNSTABLE k LCX' UON 13 /gQrA R J. _ SEWAGE # VULAGE - CZy l EV,�� ASSESSOR'S MAP & LOT 25'/ 113 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IOro G41 "LEACHING FACILITY: (type) C¢,SSn�lD I _ (size) G W X 7 T :r NO. OF BEDROOMS BUILDER OR:OW14ER 1 U—Tt". PERMIT DATE:' COMPLIANCE I%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 1 aching facility)l Feet Furnished by S �G ASr ltlry rya- 377 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED J U L 10 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 13 Laura Road Centerville, MA 02632 Owner's Name: Ruth Petti Owner's Address: Same Date of Inspection: June 28, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 251 Osterville,MA 02655-0049 Parcel: 113 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: OL11 Date: July 6, 2003 The system inspector shall su t 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. 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: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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 '/z 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.] No (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: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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: 13 Laura Road Centerville, M4 Owner: Ruth Petti Date of Inspection: June 28, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [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: Currently occupied CO MMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd 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: None on file-per treatment plant Was system pumped as part of the inspection (yes or no): Yes If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: Owner pumped system after the inspection for 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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: 12" 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 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 12" 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 outlet baffle was present. A deck covers the inlet cover. There were no signs of leakage. 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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: None (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.): 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: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 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: I 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 overflow cesspool was 6'W x 7'T x 9'6"bottom to(trade and had approximately 5'of water on the bottom. The water level was high due to a leak in the bathroom which was found. The cover was 6"below Around. 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 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 Map: 251 Parcel: 113 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. o A l3 o� 013� 37.6 10 . Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 28, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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 the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 35'+/-to groundwater at this site. This report has been prepared and the system inspected and passed 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 system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 13 Laura Road Centerville, MA 02632 Owner's Name: Ruth Petti Owner's Address: Same Date of Inspection: June 27, 2001 R 0 61�a1 Name of Inspector:(Please Print) James M. Ford Mailil ng Addre s: P O.QBo.9ord .' Map: 251 '1004 1 DAS EFT Osterville,MA 02655-0049 Parcel: 11 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: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority A Faiis Inspector's Signature: Date: June 30, 2001. The system inspector shall sub 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. Notes and Comments s 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 a a Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 13 Laura Road Centerville. MA Owner: Ruth Petti Date of Inspection: June 27, 2001 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 systeni­required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ass ins ection if with a royal of th Board-of Health )- pass P ( PP.. ... _. ).. 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: 13 Laura Road Centerville. MA Owner: Ruth Petti Date of Inspection: June 27, 2001 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 v j 'L '. . _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100'feef 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: Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 27, 2001 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 cr 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 'h 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,Lpf 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 aDEP 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.] No (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: 13 Laura Road Centerville, MA Owner: Ruth Petti _.,... . ., ._ . .. Date of Inspection: June 27, 2001 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? n/a 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 thesitein'spectedfor°signs ofbreak'out'?' -.-- Were all'system components;excluding the7SAS' 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)]. I t` t -.r... _ 5 5 N Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 13 Laura Road Centerville. MA Owner: Ruth Petti Date of Inspection: June 27, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [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)): 2000-23,000 gals.; 1999-26,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of desi' flow seats/ er§oris/s"ft etc) sign ( P.. q , _ : • 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: None on file-per treatment plant 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 (describe) Approximate age of all components,date installed(if known)and source of information: Unknown 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: 13 Laura Road ___....._.__.... :. ,. •' ; w Centerville. MA Owner: Ruth Petti Date of Inspection: June 27, 2001 WELDING 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: 12" 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 gal. _ Sludge depth: 2" _ Distance from top of sludge to bottom of outlet tee or baffle: 29" - Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" 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 outlet baffle was present. A deck covers the inlet cover. There were no signs of leakage. • N (locate n site plan)GREASE TRAP. one oca o ( P ) 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;=liq did,evels as related to outlet invert,evidence of leakage,etc.): F Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM-INFORMATION (continued) Property Address: 13 Laura Road Centerville, AM Owner: Ruth Petti _ Date of Inspection: June 27, 2001 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: Rallons 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: None .(if present must be opened)..(locateon 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or n.o): 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: 13 Laura Road Centerville, MA Owner: Ruth Petti - Date of Inspection: June 27, 2001 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: 1 _ - - - - 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 overflow cesspool was 6'Wx 7'Tx 9'6''b6ttomi6Qra4 dhd'had2'6"ofwaterori.thr '6 ttom`',Tlie-scum'line'was 3'up from the bottom. There were no signs of failure. The cover was 6"below grade. 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 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 13 Laura Road Centerville, AM Owner: Ruth Petti Date of Inspection: June 27, 2001 Map: 251 Parcel: 113 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. aAc k . A ' i k Ai- aS i gl 31 (v 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI'ON (continued) Property Address: 13 Laura Road Centerville, MA Owner: Ruth Petti Date of Inspection: June 27, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells i. Estimated depth to ground water 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,groundwater elevation: The bottom ofthe overflow cesspool to grade was approximately 96". Using the Barnstable topographic map and water contours map, the maps were showing approximately 351'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date o inspection. This report is P P P .f P P 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 system, the inspection and/or this report. 11 SYSTEM PROFILE NOTES F N. AT EL. 72.6' ACCESS COVERS TO WITHIN 6' OF FIN. GRADE Nor Tod 1. DATUM IS APPROXIMATE NGVD ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE wTTHIN s' OFFIN. GRADE 2. MUNICIPAL WATER IS EXISTING 71.0' MINIMUM .75' OF COVER OVER PRECAST / A sRd 2% SLOPE_REQUIRED._OVER SYSTEM- 7Q:a3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 0.1' INSTALL INLET RUN PIPE LEVEL XISTING TEE 1" ABOVE. _ FOR FIRST 2' OUTLET INVERT 2" DOUBLE WASHED PEASTONE 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO OR GEOTEX�LE FABRIC H- 1 O#*EXISTING 1000 o ISTIN GALLON sEPTiC TANK s8.7 f �=-sum 67.a' GAS 5. PIPE JOINTS TO BE MADE WATERTIGHT. BAFFLE 66.68' �� 66.51 I N�equaquet �° 0 66. ' ... - 0 3 AT SIDES 6. CONSTRUCTION DETAILS TO BE- If4 ACCORD-ANCE- WITH a _ ems' CRUSHED STONE OR MECHANICAL 2' 2,25' AT END MASS. ENVIRONMENTAL CODE TITLE V. COMPACTION. (15.221 [2]) 80 o o�� 64.5' DEPTH of FLOW = 4` 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO L TEE SIZES: BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. INLET DEPTH = 1Q" 3/4" TO 1 1/2" DOUBLE WASHED STONE Route 28 OUTLET DEPTH 14" ( 17 9G SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. LEAC ' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY 9.5 LO_nt t�__ MAP. FOUNDATION-EXISTING SEPTIC TANK 12 D BOX 3 WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION V1J _ OBTAINED FROM BOARD OF HEALTH. SCALE: 1" = 2,000't *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. LOCATIONS OF ALL -UTILITIES AND-ALL _ 10. CON-TRACTOR SHALL BE_ RESPONSIBLE FOR CALLING SEPTIC TANK SIZE -AT 1000 GALLONS AND DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 251 PARCEL 113 BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE BOTTOM TH-1 EL. 55.0' - PRIOR TO INSTALLING ANY PORTION OF OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ; SEPTIC SYSTEM-- COMMENCEMENT OF WORK. LOCUS IS WITHIN GP OVERLAY DISTRICT 11. EXISTING_ LEACHING FACILITY SHALL_BE PUMPED AND _ ..LEGEND- REMOVED 100.0 PROPOSED SPOT ELEVATION 12. ANY UNSUITABLE MATERIAL ENCOUIVTER'ED -SHALL -BE REMOVED 5' BENEATH AND AROUND THE PROPOSED +100.00 EXISTING SPOT ELEVATION LEACHING ,FACILITY. - 100 PROPOSED CONTOUR SYSTEM - DESIGN:- 100 EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 440 GPD ©bra• USE A 440 GPD DESIGN FLOW SEPTIC TANK: -440 GPD `(2) = 880 10 S **RE-USE EXISTING 1000 GAL. SEPTIC TANK O 0 00, � o � _ f' LEACHING: y y TEST LE LOGS 3 SIDES: 2 -(40 + 10:3) 2 (.74) ;= 149 GPD__ O � BOTTOM � 40 x 10.3 (.74) = 304 GPD ENGINEER: DAVID FLAHERTY, R.S., SE2755 �� o \�FS LOT 14 TOTAL: 612 S.F. 453 GPD f WITNESS: DONNA MIORANDI, R.S. ( f 10,065t SF Q USE (5) "3050" INFILTRATORS IN A TRENCH CONFIGURATION DATE: AUGUST 13, 2007 0.2f AC. WITH 2.25' STONE AT ENDS AND 3' AT SIDES < 2 MIN/INCH PERC. RATE -- rn � °p � EXISTING 4 BR _ CLASS I SOILS. P# 11862 0 - _ �' DWELLING- t ( rn i TOP OF FNDN ( MA rn 4, o� EL 72.6' APPROVED DATE BOARD- OF-HEALTH ' ELEV. ELEV. LRG. OAK " `V ' " 68.0' BENCH MARK - CORNER OF • 68.0 0 _ _ . � \ TITLE 5 StTE PLAN- CONC AT- STEPS TO BASEMENT a' 16 FILL 66.7, 14 FILL 66.8 DOOR ELEVATION = 68.3 N _)` 0 d OF " " TH 2 b of A A o 13 LAURA RD. LS _ LS <v -1 CCENTERVILLE) BARNSTABLE, MA- 1 OYR 3/2 1 OYR 3/2 19" 66.4' 20"- 66.3 rt l PREPARED FOR •' r. BORTOLOTTI CONST.L1 LS LS 69 / " 1OYR 6/8 1OYR 6/8 ADAM HOL iT HOU E 40 64.7 4.1" 64.6 5' REMOVAL OF UNSUITABLE SOIL LRG, OAKS DATE: AUGUST 17, 2007 C C REQUIRED AROUND PERIMETER OF 90.001 p I LEACHING FACILITY, DOWN TO SUITABLE SOIL LAYER. REPLACE \ WITH CLEAN MED.. SAND. ENGINEER \ PERC MS MS TO INSPECT AND CERTIFY REMOVAL `t�OF of€-508-362-4541 2.5Y 7/3 2.5Y 7/3 �� �OF��� �ARNE&JA���� faX 508 362-9880 AFZNE OJALA -5% COBBLES 5%.COBBLES �` " CI L N down cape en gin eerin g, inc. 156" 55.0' 122 57.8' o.26OALA A No. 3 792 o Cl VIL ENGINEERS Scale:1"= 20' LAND SURVEYORS NO GROUNDWATER ENCOUNTERED /J ° o�' �S8/ONAt 939 Main Street - YARMOU THPOR T, MASS. 0 10 20 30 40 50 FEET DATE AR OJALA, P.E., P.L.S. 07-168.DWG DCE #07-168