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HomeMy WebLinkAbout0020 LINDEN AVENUE - Health 20 Linden Avenue Centerville P - A = 208 017 w- -- - '1 i i i Y Commonwealth of Massachusetts Titre 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 20 Linden Avenue Property Address. ... Terrance Ford Owner Owner's Name information is Centerville MA 02632 10/15/12 required for every pager Cltyrrown - State Zip Code - Date of Inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end.of the form. . ... Important:When A. General Information on - n the 4out forms the computer, J use only the tab.::: 1. Inspector: key to move your cursor-do not Ricky Wright use the return key. Name of Inspector B & B Excavation,inc. reb Company Name 14 Teaberry Lane Company Address Forestdale MA: 02644 Cityrrown State Zip Code 508-477-0653 S14595 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. Thp inspection was performed based on my training and experience.in the proper function and ntenancj%f orate sewage disposal systems.. I am a DEP approved system inspector pursuant tdSection t 340 0� Title 5(310 CMR 15.000). Thesystem: (12 ® Passes, ❑ Conditionally Passes ❑ Fails" - ❑ Needs Further Evaluation by the�Local:Approving Authority " 10/15/12 - 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•11/10 Title 5 Official Ins ec n Form:Subsurface Sewage:Disposal System.•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 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: 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 L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Z.ip 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 Ej 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 wM 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments wM 'r 20 Linden Avenue s Property Address Terrance Ford Owner Owner's Name information is Centerville MA 02632 10/15/12 required for every.. page. City/Town State Zip Code. Date of Inspection -- C. Checklist Check if:the following have been done. You must indicate"yes" or"no".as to each of the following: Yes.. No El ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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 El ® 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. El ® Determined in the field(if any.of the failure criteria.related to-Part C is at issue ..approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System.Information Residential Flow Conditions: Number:of bedrooms(design): 4 -. - Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 440 t5ins•11... Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Sept 2012Date 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 gal Sludge depth: no sludge 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 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. CitylTown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. 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 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. CitylTown 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Avenue �M Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. Cityrrown 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.): At time of inspection d-box appears to be in good condition. 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 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ . leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 ❑ 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.): At time of inspection leaching appears to be in good condition. No sign of hydraulic failure 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 1 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 l Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 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 A 0 a Aj= q3 ' A2; 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 wM 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 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: >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: inspection report dated 3/4/09 ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 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 �M 20 Linden Avenue Property Address Terrance Ford Owner Owner's Name information is required for every Centerville MA 02632 10/15/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is Centerville MA 02632 March 4, 2009 required for State Zip Code Date of Inspection every page. City(rown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the l../ computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name red 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 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 C March 4, 2009 I ,pector'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. L-A -1 01 09.29 Patalino.doc-08106 Title 5 Official Inspection Form,Subsurface Sewage Dispo 1 System• age 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is Centerville MA 02632 March 4, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 1.5.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time leaching system is functioning properly. 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 09-29 Patalino.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 09.29 Patatino.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® 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. 09-29 Patalino.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ww 20 Linden Ave. Property Address Patrick Patalino Owner Owners Name information is required for Centerville MA 02632 March 4, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-29 Patalino.doc-08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. Cityrrown State Zip Code Dale 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)) 09-29 Patalino.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 2 Months prior to inspection. 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: t Last date of occupancy/use: Date Other(describe): 09-29 Patalino.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 t Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 10/15/96 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-29 Patalino.doc-08106 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 w 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is Centerville MA 02632 March 4, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 4" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------ --- --------------------- 10.5' long x 5.8'wide- 1500 gal. Dimensions: 0" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 011 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 Measured How were dimensions determined? 09-29 Patalino.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is Centerville MA 02632 March 4, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank has liquid only, no solids Tees are intact and clear with liquid level at bototm of outlet invert. 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): 09-29 Patalino.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w " 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is Centerville MA 02632 March 4, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: El Yes ❑ No Ala e 9 Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.).- No solids or high stains present liquid level at bottom of outlet pipe Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-29 Patalino.doc•08106 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 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 Cultecs. ❑ 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 was probed and no evidence of saturation or surcharge were found. 09-29 Patalino.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 09-29 Patalino.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Linden Ave Water Service i ! / ! / / J%r r / ! f / / r ! / r %r J / r r / ! / ! / / ! r /\ Y \ Y \ \ \ Y \ Y Y \ .\ \ \ \ \ \ \ \ \ \ \ \ \ / / r / r / / / J r / /\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ ♦ \ \ \ \ \ \ Y \ / / ! / / / / r f ! / IN \f f J ! / f ! f ! r ! r\ \ \ \ \ Y \ \ \ ♦ \ \ \ \ Y ♦ \ \ \ \ \ \ \ \ \ \ \ Y \ / / r / / r ! / / / r r ! / r J ! ! / r J ! ! • / / • i r r ! \ \ \ J / r /\/ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Y \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \% \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Y \ \ \ \ \ \ \ \/ /%/ / / ! \J\/\ / / / f / / / / r / r 27 43 5 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Linden Ave. Property Address Patrick Patalino Owner Owner's Name information is required for Centerville MA 02632 March 4, 2009 every 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 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 20 and topo map shows property at el. 40. 09-29 Patalino.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Jet TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 20 Linden Ave Centerville MA 02632 Owner's Name: Fred Ruland Owner's Address: 329 Concord Road Lincoln MA 01773 Date of Inspection: August 14,2006 Job#06-220 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a D .111111 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �����°�'H 0 Passes o�'. Conditionally Passes Needs Further Evaluation by the Local Approving Authority _ M. •:y Fails 7k. Inspector's Signature: Date: 8/14/06 '�.,� • F���� �� 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. Notes and Comments: Tank has liquid only and is not in need of pumping at this time.No evidence of saturation was found in leaching system. ****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. } 7" E=f c Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 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 I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5,ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. I� Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ _X_ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks? _ _X Has the system received normal flows in the previous two week period? _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? P g _X _ Were all system components,excluding the SAS,located on site? _X_ _ 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? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440 Number of current residents:0 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Yes Water meter readings,if available(last 2 years usage(gpd)): Two years total:30,000 gal.=41 gpd. Sump pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 10/15/96 Were sewage odors detected when arriving at the site(yes or no): No . Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 BUILDING SEWER:XX (locate on site plan) Depth below grade: I' Materials of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 4" Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5`long x 5.8'wide—1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or battle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank has liquid only,no solids Liquid level is at bottom of outlet invert and tees are intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or high stains present. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: 4 Cultec's leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: _overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Cultec chambers have no access covers,probed stone and soils around SAS and found no evidence of saturation. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 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. Linden Ave Water Service 1 5 7 43 5 N Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Linden Ave,Centerville Owner: Fred Ruland Date of Inspection: August 14,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el 20 and topo map shows property above el.40. "q 01'7 Fee THE COMMONWEALTH OF MASSACHUSEfTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS Tippfication for Ptgoml *p!5tem COtt6truction Permit �0 Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—2 7 3 3 20r' venue, Centerville Elaine Renzi 0 Lynden Ave. Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm.E.Robinson Sr. P.O.Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms Garbage Grinder(no) Other Type of Building.__/� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 consisting of 1500 al . Tank D-box and tatege '330 high capacity, stone packed inf iktrators . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and of He Signed A Date Application Approved by Application Disapproved for the following reaso s Permit No. Date Issued .00 V 10 d^ /Fee $40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLESfMASSACHUSETTS ZIpplicatiou for Migpogal *pgtem Cott.5truction Permit i Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5_2 7 3 3 20 tyrrd r venue, Centerville Elaine Renzi Q17)GAI 20 L nden Ave: Centerville 'Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm.E.Robinson Sr. P.O.Box 1089, Centerville, MA Type of Building: DwellingNo.of Bedrooms 3/�/ Garbage Grinder(no) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures t Design Flow gallons per day. Calculated daily flow gallons. Plan Date ' Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 coTisksting of 1500 al. Tank D-box, and tltrzee #330 high capacity,_ stonepacked infiktrators. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in-accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and of He Signed j Q Date Application Approved by Application Disapproved for the following reaso164t s r f Permit No. Date Issued '+ fV } THE COMMONWEALTH OF MASSACHUSETTS , PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Renzi Certificate of Compliance .4 THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(.x)on ' by Wm.E.Robinson Sr.Septic SrVar Elaine Renzi )ox at 20 LyndenAvenue, Centerville ha en constructed in accordannc~e with the provisions of Title 5 and the for Disposal System Construction Permit No. 4 dated /rl5'"'• ~ ?�'L Use of this system is conditioned on compliance with the provisions-set forth belo v i No. Fee $40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION =BARNSTABLE. MASSACHUSETTS Renzi mioo.�al *patent Cougtructiou vermit Permission is hereby granted to Wm.E.Robinson Sr. , Septic Service to construct( )repair( x)an On-site Sewage System lgcated at 4P L.ycnden avenue, Centerville S and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special condition`s. All construction Est °e completed within two(ly ears of`the date below./ ,,, o e Date: (� Appr 0ed by CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I,William E. Robinson,Sr.,hereby certify that the application for disposal works construction permit signed by me dated: 2 " /1 concerning the property locatedat 20 Lynden Avenue.Centerville. meets all of the following criteria: *There are no wetlands within 300 feet of the proposed septic system *There are no private wells within 150 feet of the proposed septic system *The observed groundwater table is 14 feet or greater below the bottom of the leaching facility *There is no increased in flow and/or change in use proposed *There are no variances requested or needed SIGNED:&, DATE:1�} LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). ci ri 60/W Commonwealth of Massachusetts - {� Executive Office of Environmental Affairs ¢° Department of No v Environmental Protection `' wwrn 1=.wwa Na Tn dr Co:a ArS.o p"wuccl tt GWAMM SUBSURFACE SEWAGE DISPOSAL SYSTEM[INSPECTION FORM PART A CERTIFICATION prop"AyAddrese 20 Ltnden Avenue, Centerville AddressofOweer.Elaine Renzi Data of Inspection: (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accinste and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper fltnetion and maintenance of on•ite se disposal systems. The system: _✓ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fail / Inspector's Signature: 60 1,L � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A) PASSES:have not found information which indicates that the system violates any of the failure criteria as defined is 310 CMIt 16.909. Any failurs criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or ezfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) i one WInW Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-5WO �4)Primed on Recycled Paper 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PsopertyAddresse 20 Lynden Avenue, Centerville Owner. Elaine Renzi Date of Inspecdow B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to Woken or obstructed pips(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pips(s). The sysbm will pats inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed . Cl THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require ftuther evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. I) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 9 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply m'tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system ands within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well is i4ee &om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 9) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOS"SYSTEM INSPECTION FORM PART CERTIFICATION(oontinuad) PvapertyAddrwm 20 Lynden Avenue, Centerville Owner: Elaine Renzi Date of Imrpaotioo: D) SYSTEM FAILS: I haw determined that the system violates one or more of the following failure criteriaodet . in*as b m ill e n 1b.8 y The ed tbo this determination is identified below. The Board of Health should be contacted to determims what"'�bed to cos tailor• rent due to an overloaded or clogged SAS or Cesspool. _ Bac1mP of sewage into facility or system compo Discharge or ponding of effluent to the surface of the ground or surfacee waters due to an ovwk.sdad or dogged SAS Of ._ spool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ossspOol.— dayflow. _ Liquid depth in cesspool is leas than 6"below invert or available volume is lea than 112 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped pound to elevation. Any portion of the Soil Absorption System, cesspool or privy is below the high gro Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well' — ter than 60 feet from a private water supply+well with no portion of a cesspool or privy is lea than 100 feet but analyzed to be acceptable,attach COPY of well water analysis for acceptable water quality WAlysu• If the well has been analy coliform bacteria,volatile organic compound , ammonia nitrogen and nitrate nitrogen' E,LAW SYSTEM FAIIS: following criteria apply to large systems in addition to the criteria above: S )and the system is a significant threat to Public ,�"stain serves a facility with a design flow of 10,000 gpd or greater(Large ystem health and safety and the environment because one or more of the following conditions eli't the system is within 400 feet of a surface dAnking water supply the system is within 200 feet of a tributary to a surface drinking water suPPb' the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(TEA)or•sapped Zone II a public ° water supply well) hence with the���treatment px'oi�m ' such system shall bring the system and facility into tltll comp tics The or operator'of W oral office of the Department for hither informs of S14 CMR 5.00 and 6.00. Please consult the local regi S (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST pmpwtyAddeuss: 20 Lynden Avenue, Centerville Ow"r. Elaine Renzi Daw of Inspedim Cbwk if tba following have been done: information was requested of the owner,occupant,and Board of Health. "✓None of the system components have been pumped for at least two weeks and the system has been receiving normal AM rMA" during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 6!jy built plans have been obtained and examined. Note if they are not available with N/A. VXM facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow l/The site was inspected for signs of breakout. ✓A11 system components,excluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or teas,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. '4 T size and location of the Soil Absorption System on the site has been determined based on misting information or approaimsted by non-intrusive methods. 111�4 facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. 4 (revised 11/03/95) suBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropeetyAddresw 20 Lynden Avenue, Centerville Owner. Elaine Renzi Date of Inspeotiow FLOW CONDITIONS ID D0s�Dt��[,�gailon.L Number of bedrooms: , / Number of currant residents:_ G~grinder(yes or no):A..- v , La=ft oonnectid to system(yes or no): Sguonel we(yesor no):_A-- 1 9 9 3—1 9 9 4 31 Water meter readings,if available: CZ Last date of occupancy: CO MMIALANDUSTRIAL: Type of establishment: Design flow. gel1°m/day Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non4anfta7 waste discharged to the Title 5 system: (yea or no)_ Water meter readings,if available: Lost dab of occupancy:___ OTHER:(Describe) Last dab of occupancy: GENERAL INFORMATION PUMPING RECORDS syd source of information: System as part of inspection: (yes or no)_ If yes,volume pumped:-------—g&Uonx "Moo for pumping TYPE O Septic tanlddistribution bos/soil absorption system Single cesspool _ Overflow cesspool _— Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other,(explain) AppRO]aMATE AGE of all components,date installed(if known)and scarce of information: A,,� �7 �J 4 Sewage odors detected when arriving at the site: (yes or no)A (revised 11/03/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) pmpertyAddraw 20 Lynden Avenue, Centerville Owner. Elaine Renzi Date of Inspection: SEPTIC TANK v (locate on site plan) Depthbelow grads: metal FRF other(esplain) Material of comatruction•oon�— Dimsndcns: '� ► • Sludge depth: Distance ham top of sludge to bottom of outlet toe or baffle:� Scum thiclmess:— ('!�— , 1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baMe:-4.'L Comments: ' (recommendation for pumping,condition of inlet and outlet tees ba�,depth� 1eve1 in relation to autkt invert,ett'uct� evidence of leakage,etc.) a E TRAP-.— A site plan) Depth low grade: Mabrisl of coffin:concrete—metal—FRP—other(explain) ficum from top of scum to top of outlet tee or baffie: from bottom of scum to bottom of outlet tee or baffle: b: level in relation to outlet invert,str%rctural intW'tyo ( lion for pumping,condition of inlet and outlet tees or baffles,depth of liquid evids of leakage,etc.) 6 (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) �Adde 20 Lynden Avenue, Centerville Elaine Renzi Date of Inspectbd TI OR HOLDING TANK:_.. (bate sits plan) Depth Vad°• _metal_FRp_other(ezplain) Idatarlal conatrxtion:concrete Gpacitr O1L' Dealp onsldaY Alarm 1: Common ( of inlet tee,condition of alarm and tloat switches,etc.) DISTRIBUTION BOX* ✓ (bate on sits plan) Depth of liquid level above outlet invert: Comments: evidence of leakage into or out of boa,etc.) (note it level and distribution is equal,evidence of solids carryover, PUMP ZR:_ (locate site plan) pampa working order:(Yes or no) ts: ( of pip chamber,condition of pump and appurtenance,etc.) 7 (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PnVertYAddrem 20 Lynden Avenue, Centerville Owaa Elaine Renzi Date of Inspsotioo: ,/ SOIL ABSORPTION SYSTEM(SAS$V (looms cc site plan,if possible;wcavation not required,but may be appradmated by non-intrusive methods) If aft determined to be present,explain: Type: leaching pits,number._ lerbiug chambers,number leeching gallriss,number leaching trenches,number,length: lachin fields,number,dimensions: overflow compool,number: Comments:(note condition of moil,sits of hydraulic failure, level of potylim,condition of vegetation,etc. CNN LS:_ (locate on 't plan) Number configuration: Depthtop liquid to inlet invert: Depth of so layer: Depth of layer: of oempool: Material of eeasbuction: Idicattion groundwasr: (cesspool must be pumped as part of inspection) Comm en t:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc. PRIVIfe (locate on pLn) Material of Dimensions: Depth of solids: Comment:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) i (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddrew 20 Lynden Avenue, Centerville Owwer. Elaine Renzi Date of Inspectlew S=MH OF SEWAGE DISPOSAL SYSTEM: include tW to at laud two permanent references landmarks or benchmarks locate all wells within 100, LU 0 'r �a `�I I I � � G O DSPTH TD GROUNDWATER Depth t, water` -r feet method of determination Or approximation } � (revised 11/03/95) 9 TOWN OF BARNSTABLE LOCATION _ L,°� � ��e- #-=1705P VILLAGE 0-ftt-erVitkJ2 ASSESSOR'S MAP&PARCEL 1149qiO�'S NAME&PHONE NO.�z 0�o A At SEPTIC TANK CAPACITY 600 LEACHING FACILITY.(type) �� Cif S (size) NO. OF BEDROOMS q OWNER<—Z -c ZAO PERMIT DATE: 1 DATE�v,5? Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY f f f f f f ! I (', J f !�!•f % F:%'I f f ! r ! r I ! f,i I I ♦ 4 1 \ k \ 1 \ \ k \ \ 4 4 \ h h \ h \ \ 4 ♦ \ ♦ 1 \ \ 4 4 4 4 \ \ \ \ 1 4 4 4 4 \ 4 4 4 4 4 4 h f f f f f ! f I r l f f f f f f J f f f ! ! f f f f ! f J ! f f f 4 4 \ \ 4 \ 4 4 \ f f J f f f f f 27 43 �. 5 TOWN OF.BARNSTABLE LOCATION ® C..i ylC � En� VILLAGE tkr'011I.Q 'ASSESSOR'S P&PARCEL AME&PHONE N0. -a—e k SEPTIC TANK CAPACITY ' 1500 LEACHING FACILITY: (type) '1 L4&IeC. (size) NO. OF BEDROO S OWNER v PERMIT DATE: "�Ibf�DATE: 45 l'/L' o(p bt Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r y Linden Ave ater Service II 15 i 7 43 5 �1 TOWN OF BARNSTABLE LOCATION. ad 1/1110,15'rl AL VA'f SEWAGE # V►LLAGE ' �?E/� �','�L/c ASSESSOR'S MAP & LOT4 INSTALLER'S NAME&PHONE NO. rf2M /P QiS'O IS' 7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS L BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ��!�-��/> f � I P c- v a