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HomeMy WebLinkAbout0100 LIAM LANE - Health 100 Liam Lane A= 167- 016 -012 Centerville ! 1 3 i i s Commonwealth of Massachusetts ,w, Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I.,-• •e`>` 100 Liam Ln ._ T Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 M971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty 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 7-10-19 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 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 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form � wa I,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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:l ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Co nditionalPass" 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 i TOW OF$AAN5TABI.E. ocA ort, /QD = L h -SEWAc # VILLA. c�v (.I e ASSESSORS D�STP�:L1B�`5 NAME�P�I4I�lE NO: SBP1 C 'A CAPACrr LgACMG 1PA.CUM (type) �•!� (sue). . � � A6 IL;1pI OR PJgRfI T'3a�.'TEi Cf�1VII'"UA TGB ` Aratiot��9�stti�a Bstviesn Vie; ,,, tvlxituci Adjustierl Graucfwtec'l�ble:a the Bttotn of Xachtn�F �liy prhhA6 ill BMW d+t+`r:;apply weU and t eac�in$paciliry d��a3+�reifs exist ;;otc sgt�ce w�tEua 2A0'fe�t o�iaac>ai,ng faailt�'y�) Eder �let9azid aml lLoac�Ing t sc�lisy(if any w {antl�exist &gee ••�i:ta n U0 feet Of teaming�' �►}. G f r A ► /r7 o � oa i ,�-a• Y7 ' A,q-S9 i c Commonwealth of Massachusetts Title 5 Official Inspection Form ? i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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 pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Ir w_� ',i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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 i Commonwealth of Massachusetts 3, Title 5 Official Inspection Form C�'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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 ❑ ❑ 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 II Commonwealth of Massachusetts r� Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 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 C�'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is Centerville MA 02632 7-10-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form �bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 4,"" T, 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town 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: N/A 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 r� 3 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is Centerville MA 02632 7-10-19 required for every 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: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Tank has minor tree root intrusion. Recommend regular pumpings to keep under control. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form i.'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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 �r Title 5 Official Inspection Form Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Good condition with water at working level and no sign of back-up from pit. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ;w Title 5 Official Inspection Form p 'iCi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town 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: 1-1000 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts r� Title 5 Official Inspection Form �I ws Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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.): Leach pit in good condition and empty at inspection with stain line at 36" off bottom of pit. 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 Commonwealth of Massachusetts a ,w, Title 5 Official Inspection Form i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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 hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 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 A -I W-31 O 1 1 r A - 3 Co #',3 wUA -A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "1 100 Liam Ln 'mot Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town 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: 20 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: USGS and town maps show groundwater at greater than 20'. 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 r� Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Matt Dellabarba Owner Owner's Name information is required for every Centerville MA 02632 7-10-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is A required by law. DATE: 60 o-',f f Fill in please: APPLICANT'S YOUR NAME/S: VIA �D i'GP�tr k0 `� . T BUSINES ECM S_ YOUR HOME ADDRESS: DU �.tt TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS 1�I VI e e) . e Ty PE BUSINESS v !'' IS THIS A HOME OCCUPATION? ,. YES _NO ADDRESS OF BUSINESS` /� 6�1'1 ?YI(- (!t�►�-� )i �LQ MAP/PARCEL NUMBER / (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — [corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISPh OFFIn�M This individual hader ir quire ents t lat pertain to this type of s W99 COMPLY WITH HOME OCCUPATION Au g tur RULES AND REGA)LATIONIS. FAILURE TO OM ENT �. COMPLY MAY RESULT IN FI 7 K, 2. BOARD OF HEALTH This individual has been �d of the permit requirements that pertain to this type of business. Au hori ed igna re* COMMENTS: 1I VI 46 --tt ;e did , I 0 VI 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: t: TOWN OF BAR.NS'i:ABLE .t?CATIC7N `�D L i r-, L vt SEWAGE # I$b'L sG1E e✓r¢rl-d e _.____._ ASSESSOR'S LOT NSTAL4EWS NAIVM&PHONE N0. ;EPnC TANK CA.PACTTY e d6 ,EACH NG FACILl' , (type) ���- (size) /acTo 40.OFBEDROOMS_ 3_.....--. WILDER OR 'ERMITDATE: C0WLIANCE DATE: aparation Distance Between tltc: Aaximum Adjusted Groundwater Table to the Eotiom of Leaching Facility _ eet �ravate Water Supply Well and Leaching Ptacility ,(If itny wells exist on Site or within 200 feet of leaching facility) ;, - --I _ idge of Wedand and Leaching Facility(If any wetlands exist within 300 feet a•leaching facility) Pect rurnished by c54w o � 00 l7E D � j4-D-�G' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness�checklist at the end of the form. A. General Information 1 1. Inspector: J,1� bq v� Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name - 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-29-11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and..the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 Tide 5 Official Inspection Form:Subsurface Se ge Disposal System-Page t of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure'criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 100 Liam Ln �M Property Address Emmanuel Boulogne Owner Owner's Name information is Centerville MA 02632 11-29-11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due_to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑- ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® ''Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a.design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to,each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface.drinking water supply ❑ ❑, the system is within 200 feet of a tributary to a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City1rown 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2011 Date CommerciallIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not pumped last 2yrs 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)(f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" I t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 100 Liam Ln. Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number:' 1-1000 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.): Leach pit in good condition with water at 18"from pit bottom and stain line at 30"from pit bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 100 Liam Ln ��M yey Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Q �? C. 00 Q� t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. thins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 100 Liam Ln Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City[Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-29-11 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. U V� t5ins•11/10 Title 5 Official Inspection Form:Subsurfa Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 4.00 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 ❑ El, Area IWPA)or a mapped Z666 II of'a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityfrown 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 t r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped summer 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts , u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 30"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 6" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments ;M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official . Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from trench. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-4'x6Vx2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench is in good working order with no sign of back-up into d-box or surrounding stone. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate cia site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately . B • o D t� -< 91 ,9_11./, d �a, t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 442 Prince Hinckley Rd Property Address Martha Skoegard Owner Owner's Name information is required for every Centerville MA 02632 11-29-11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i - - Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is Centerville MA 02563 11/13/09 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:When filling out forms A General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. t6:1 Company Name 185 Ashumet Road Company Address Mashpee MA 02649 City/Town State Yip Code 508-539-7966 3080 #" Telephone Number License Number 01 B. Certification CO I certify that I have personally inspected the sewage disposal system at this address and that ti 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 i 0if � .Fh ❑ Needs Further Evaluation by the Local Approving Authority 11/13/09 tA SHAY Inspector's Sign re Date J�°SpTIV\ � The system inspector shall submit a copy of this inspection report to the App y (Board of Health or DEP)within 30 days of completing this inspection. If the system is a s ed 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. 100 liam lane,centerville•03/08 Title 5 Official Inspection Form:SubsurfAispo's I at System•Pae of 15 9 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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.- leach pit has 1' Liquid-2.5' stain line noted 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 100liam lane,centerville•03/08 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 a 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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: ❑ 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 L,00 Ia100 lia supply well. m lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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 ❑ ® 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. 100liam lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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. 100 liam lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection F r Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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? ® ❑ 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)] 100 liam lane,centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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: 3 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 years usage (gpd)): — Sump pump? ❑ Yes ® No Last date of occupancy: Current 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): 100 liam lane,centerville•03/08 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 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: — gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1982 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No L,11m lane,centerville•03/08 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 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented 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: e r -y s a Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5x 5' x 8' - 1000 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 18 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 14" How were dimensions determined? Measured 100 liam lane,centerville•03/08 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 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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.): Tank in good condition, inlet tee in good condition, outlet Baffle in good condition. 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): 100 liam lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form fSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 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 D-Box Present 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.): One outlet to tank-no evidence of cracks or leaks or solids carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 100 liam lane,centerville•03/08 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 a 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 page. Cityrrown 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: 1-6'diam x 6' D ❑ 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.): SAS fuctioning properly, 1' liquid in pit, 2.5' stain line noted 100 liam lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts -ttW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 100 Liam Lane _ Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 page. Cityrrown 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.): 100 liam lane,centerville•03/08 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 100 Liam Lane ...... ....... Property Address Emmanuel Boulogne Owner Owner's Name information Is required for every Centerville ........... MA 02563 11/13/09 ---------- 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. LAC, k c 51( V11C C, 0 100 tiarn Zane,Centerville-03/08 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 M e 100 Liam Lane Property Address Emmanuel Boulogne Owner Owner's Name information is required for every Centerville MA 02563 11/13/09 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 15 feet. refer to plans on file @BOH 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: Inspector has performed perc tests in neighborhood 100 liam lane,centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 *. 1., TOWN OF BARNSTABLE 1 OC.ATIOI�� ' ��CJ ,+�.+y L-0 SEWAGE# —'�1 1 VILLAGE ASSES SOR'S;MMA_P&PARCEL J (0a -((fl ~Q- INSTALLERS NAME&PHONE NO. J� SEPTIC TANK CAPACITY ( CoC7 an ��.ci�- LEACHING FACILITY:(type) � �� (size) G NO.OF BEDROOMS 3 OWNER &nMUK-X.;s-e_\ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J'°t' Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) &(A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching ngg:�-. ity) 1J Feet FURNISHED BY I PI' 440 -�Csa�4 . C'°`e. o 31 4 3 �d Ao Sv �T s 1 e7 0. Fps..... �...... /D THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF, HEALTH .---_------OF...............t ApplirFatiou for BiapaaFal Works Tutwtrurtiun runfif Application is hereby made for a Permit to Construct (.�- or Repair ( ) an Individual Sewage Disposal System at: .................__..--- ® /.1......._... --------......__�:_... r - ............... .....- • L ation dress 3 a or Lot No. �- &�.�................I .c- ------b .:...---- �.s .._._ ..,.�'/_.b ti ----------------------_........ .............. Owner • ................................Address .... Installer Ad red Type of Building Size Lots`{. Z Q0.___._Sq. feet U Dwelling—No. of Bedrooms_________ ____ _ Expansion Attic '9 0 Garbage Grinder - -•-- aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .----•-•-----------------------•---•------------••----.•••--•--•----•------•••••--•••••---••-••••••-••-•------•-•----•------•-...:-•••---------------- Design Flow................... __ ___ .gallons per person per day. Total daily flow------------------ gallons. WSeptic Tank—Liquid*capacity_/_©()�llons Length................ Width................ Diameter................ Depth............... x Disposal Trench—No_______________(__,. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... ... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( — Dosing tank ( ) Percolation Test Resu s Performed by._--------------wG __. ___ ate.__._..._..__ _7 � aTest Pit No. 1__ tf__minutes per inch Depth of Test Pit______J__ Dep to ground water___jrf/ (i, Test Pit No. 2...._: minutes per inch Depth of Test Pit.................... Depth to ground water.__ O Description of Soil---------•••--•-••---••-•••-•••-_0. Or ��. (� 7-F (� ��� x .....................I------•-----•---------------•---- UW -----------------------------•-••------- ••••••---... �--- ----••••----•------- - {- e Nature of Repairs or Alterations— ns e when applicable____________________________________ _ ---------------------•----------•--------------------------•---•--._._....--••-•-••-.....•--••-•••--•-•---•--•••••••••---••-•••-••••-•--••-••-------••------........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code— The undersigned further agre not to place the system in operation until a Certificate of Compliance has been issued by the board of iealth. Signed.......... ... Application Approved By............ .................................... Date Application Disapproved for the following reasons:--•--••--•---••--•••--•-•-•--------••--•---••------•-••••••--•._.••••-••---•---••••••-----•---••--•••-•--------- .......-•••••••--•••---------•••-----•••-•---•----•-•-••---•-------••--•••••----•--....-•-•---_._...-••- Date PermitNo......................................................... Issued....................................................... Date t Jb No..��.�y..�.`l.. - Fps...�.$..•�.'......._ THE COMMONWEALTH OF MASSACHUSETTS , ,. BOARD OF HEALTH .._ 04,.V ..............OF..............! ............. , pphra#ion for Dis,pag tl IVoxks Tons rudivit JIrrutit Application is hereby made for a Permit to Construct,(i�or Repair ( ) an Individual Sewage Disposal System at: ..................................................................t 4. ` -• • .. -• ..--•- - � ` - .... - ._.._.. L cation/ AddressNo, ^* ......................»__. _1�,' Ar....l..r.. » - ,6_'.� or Lot -) ` . ......................... �...... .._ 1 - ""y Owner � �Tess a ,f►.5.. �' ........ / •--••---•------------------�-----•--..... :. `t•- ^ a• <'.......................... Installer Address Type of Building Size Lotq.Y,.�f` 2.......Sq. feet Dwelling—No. of Bedrooms........_.✓f...............................Expansion Attic Garbage Grinder !/ aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .. W Design Flgw..................1".. ....._..._......_gallons per person per day. Total daily flow..._..........__.. .. •,�` . ...........gallons. WSeptic Tank—Liquid capacity{.nt)(dallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—IN...............(._.. Width.................... Total Length.................... Total leaching area................ ....sq. ft. Seepage Pit No-_------------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. I z Other Distribution box Dosing tank -, Percolation Test Resu is Performed by.......:....... .�se L ` ... �?'Date.__.___._... % -- p p pdi to ground water..��'Z � Test Pit No. 1.�.� mmutes per inch Depth-of Test Pit.__. ._:��.... De bri i f P P P g E fsl Test Pit No. 2..._..__.._ .minutes per inch De th of Test Pit....:............... Depth to round water._..�!I�..�_.c►��_ O Description of Soil....._. V --•--••-••---•--•--•-•••-•-•-.........•-_. .. UNature of Repairs or Alterations—Ans er when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT Ei; ;p 5 of the State Sanitary Code— The undersigned further agre'g not to place the system in operation until a Certificate of Compliance has been issued by the board/of)health. Signed .._..4_ ..'`-ylPa. 1 ' = ?r y✓ V�� Application Approved BY a .�.. !✓a !� 9`_ ..... Date Application Disapproved for the following reasons:------•--------•------------•------------------------------•--•-------•---------------------------------...---•- .................••-•--••----••--------•--•-••--•--•••-•-•----•-••••--•---....••-----•••-----••••--•.......••---•-••-•-•-•--••••----•----•••••-•••••----•------•••••-----•••-•--•---••--••••••-•-----•- Date PermitNo......................................................... Issued....................................................... a Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I /�G'l.ah''d OF..............1 � f/ '.......... (9rdif iratr of Toutplianrr THIS IS.T ERTIFY, That the Individual Sewage Disposal System constructed b(_or Repaired ( ) by4..!' ''`°.!"``.•....-----•--------.�l�....►........ �"'.....�------:---•-----•-••---•-•-••--------------------- - ..,,,., .. � Install r�,/��"M"• at...................... O 'er has been installed in accordance wiili the provisions of TITLE, j of The State Sanitary Code as described in the application for Disposal Works Construction Permit 1V'o._�_�_ ��'' -------------- dated..............:......:......................... THE ISSUTANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUBE A GUARANTEE THAT THE SYSTEM WI F CTION SATISFACTORY. DATE..! THE COMMONWEALTH OF MASSACHUSETTS � . �. BOARD OF HEALTH l............ s . °............. � ...........OF............ .. ..T.. .- ....r "` '_.................. v � No..4919 k&;:5�' FEE..........:............ Utop al Workii Tannli#rur#ion rrutif Permission is hereby granted........................... --•- ..S_.C.0. .. ....�.. r to Construct 4>1 or Repair ( ) an Individjual_Sew spousal system .. at No.............._: .�, �(2, ----..-------- -------------------- -- = ......................... Street kr as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... .......... !,"'' ...................................... f DATE_ Boarjof Health ........•.............•••........•••••...........................- "u.,: FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' LOCATION SEWAGE PER IT NO. VILLAGE I N S T LLER'S NAM ADDRESS 1BUIL0ER OR OWNER � �f -ram DA T E. P ERMI-T ..IS-S.Y`E DATE CO'WPLIANCE ISSUED/ y �� s �Q �� � '�. � � ,G .. �b�l� , ; .�_._-- _ r ..«vim. :rxx!•.�.r.. ...:_... _. ........ _ . . t i ' .. •.N�T� t - W of OF CA Y h •f 4IY x b�i 1v e Lrl �•,( ' v.� fir•� 8 .k� 4 rf;' -` i Aq lap o P ' W \ 1 1 r;' is :55 it :. � .. _ ,• • '1... � /lYT �' � 1 3' ! yam. �.''[�-�...• y 4� 2101/. 1 . W 1 1� ��1:".r� y' a �'\ t•. ����1 ro i r v � 1 " 1F1Y4 t /& 2s' w r b-n-A a 3; T } ! E 0 ��. ��.� .:. CERTIFIED PLOT PLAN EXISTING &POT ELEVATION CAS EXISTIM0 CONTOUR ...�.... � �. o�� . ALe. .7" It /� /✓� LAN G FMISMED SPOT ELEVATIONj, FM°S ED CONTOUR - r°~• ' �, �URSCI j • � 4 No.11U9 a APPROVED.o &CAR® OF 14.9 A�o�FG'isTE�� ``' s . / 2.4,9A S/ONAG� cy SCALEl DATE AGENT DATE, 4 W 6 9A� AIMS p . T : 7 !, CERTIFY THAT THE PROP CONFORMS TO THE ZONING Lk Of AB DARNS 712 MA6 N STREET, SYa• H YA H N 6 SI. MA 9 S, SHEET,.l F ' — DATE -,REG. LAND SURVEY R®.'Fr M/,V. igAelrs.�rG .oiT .4R� �i'Oe�� T"NA, /2"8Z40J-4I # /® PY• /►9/N. JRA®�� 24+01A14 ET.E� CONCH A�� C®i�.�.P He- SWALL &,F 49RO /tf V7 70 *,TA��.�.tiN EXTRA � C®lIICP � 4 PYC P/PZ jy E.4 V Y CA.s 7' /,eO/Y C f�VE'fi Sf��L L C3 USE D M/N. P/TCM !F lIV DR/!/EN1A y-, CL E.4/V .SAND t� vogaID LEY 2- -AYER j 4"CAST - r IRON PR/PZ u o 0AL. m o a om � 1IL9 4 /4°Il ail.B/�' S7. ' e m • . s ® s s > ®� DI WA SHOO STrJNE i �4 Pen I-r. SEPrIC TA/1IdC fp • a v 'I OF PRECAST S.=. e'NY� eL�i�.�7'/® S �r e�+,> crr y S-4,0 PA _►� ' ® ® s a ®�m a e is ® P17 OR ° fl JA1aC�T DI I . C(S ®�7'LR r SEP7®dC 7'A/�IK:: 33 _ 915TRI40bT/OM so)e 33 4 A7 33. ®ISTI�/,&IrrION Z FT 1"4,G7' 1.EACMIJVa 00117' 3 3.d. FT rt -sZkVA ISE A0lSA:P A 4 SY5 7&)W 7A8411 ATION. �. L CHt VC- A11/7" ® mEmSIov A JCAL, %4" _ O e®~ ajV FT. Nd/Ib98�•,� ®o��C'!3P®l3�$',S �._ �!/b��"dl/S•!®140 � �_F7:/'�.rv. SS®/L L®G Tfl7.Q1L E TT1J*?.�'�EO FL.®W 33 GAL. ®�Y SOIL 7-EST A ' SOIL TEES702 .� 7` 57 R � LOACHIl�a /a/TS f`EL��✓ 3 4�_ �,L Y' ®ATE ®it, Sol L -•'f T 2 7 Z F S1D1E Lj--AcI lMcr ��Ar P1'r ►g"� srt P� a.- / z gzsuL7°j; kvin a-ss D 400r-rOM LZA CNING P--R-P/r Pr hd -,'1tRC0ZA'r101v RA70#1 Liss MJ,?V//IVCH TOTAL LeACH/NG ARA �.SQ F/:' R.ES.EfflveZEACRIlYcGr4�4SA _ o �-•• I `Y ALBEIT U 38374 � ,p Na.10951 G 2 ',� ': �'.�� ����� �j�• 'T�/�lt� :'�� f IST, �L. ✓, 220 ?/2 P�f.a9/:Y ST. SUM'i> i~ FrS/CPlA1 o Cs ,k b®G�GUNt7 ��/�TE� givCOU/VT�.��� Ce®s�AtT: r�eTe �L t vmv Ca1�0 UVU AsBuilt Page 1 of 1 TOWN OF BARNSTA13LE LOCATION 100 (,,4m l a l SEWAGE## ESQ-i 4 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PRONE NO. T. �SCO�1 SEPTIC TANK CAPACITY ©co an LEACHING FACILITY:(type) X NO.OF BEDROOMS OWNER C tY1MC��re� J�C�C 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) fj114 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa 'ity) Al[J), Feet FURNISHED BYZ '>I d 40 So J �« Sc� �9 0 http://issgl2/Intranet/propdata/prebuilt.aspx?mappar=167016012&seq=1 7/5/2011