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HomeMy WebLinkAbout0645 LUMBERT MILL ROAD - Health 6 6 LUMBERT MILL ROAD Centerville A = 147 — 119 - 001 SMEAD No.2-153LOR UPC 1Z534 smsad.com • Muds In USA �pFCYC% 01A floulmmimp ew �H WDESMUN 00� Commonwealth of Massachusetts - p Title 5 Official Inspection Form le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .. 645 Lumbert Mill Road ' V Property Address t�= Melissa Augustine Owner Owner's Name information is -� required for every Centerville MA 02632 1-3-19 t" 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. uuuunnu� Important:When A. Inspector Information /,.y. /36'ifq ,•�`°�<c.P'`filling out forms on the computer, o�� cyG use only the tab James D.Sears �: JAMES (P__ key to move your Name of Inspector =o. SEARS cursor-do not Capewide Enterprises _ _ : * c use the return se .? � key. Company Name l� FRTrF�� �o ��` 153 Commercial Street Company Address rnnnun �� Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Qaf,�Z� 1-4-19 ector'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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 645 Lumbert Mill Road u Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is Centerville MA 02632 1-3-19 required for every 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment. t5insp.doc•rev.7126/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road 'LJ Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 Qeespsml is less than 6" below invert or available volume is less than '/z day flow Pr7— ❑ ® 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 CM 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 I - cam' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road `J Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 CM 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? El Was the facility owner(and occupants if different from owner) provided with ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal.Tank D Box and pit. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2016-43,000Gais g ( y 9 (9p ))' 2017-44,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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: NA 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �v 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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: 1985- Permit #85-470/ 1-19 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 31" 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.): Pi eing is 4" PVC SCH -40. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I - Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 29"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. Precast H-10 Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 29" below grade. W/inlet cover at 8" and outlet at 6". Inlet tee w/outlet baffle. No sign of leakage or over loading. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form -�' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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.): D Box is 16"x16"-40" beow grade w/cover at 6" below grade. Box is new 1-19 w/one line out t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form M1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 workingorder: * ❑ 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 ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form t p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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.): Leaching is a 1000 Gal.precast pit. Pit at 31" below grade. 1'water in pit w/stain line at 10"above water level. No sign of over loading. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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.): II I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 t R- - 3L /3 4;: 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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"higq ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12-17-84Date ❑ 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: T.H.on Design plan 12-17-84 16' no G.W.. Bottom of pit at 8'-6" below grade. Bottom of pit at 7'-6" above T.H. depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form . o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 645 Lumbert Mill Road Property Address Melissa Augustine Owner Owner's Name information is required for every Centerville MA 02632 1-3-19 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 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 /v a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4phratlon for VspoBo.Y 6pstrm (ConstCUttion 3dPrmit Application for a Permit to Construct( ) Repair(><Upgrade( ) Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. lo4 S Lj Mderf Mt 11 RD Owner's Nape,Address,and T 1.No. C2Nt'civtlle 5i4A*1E HJL S_ 1131L r ca."ssA GiB6onl Assessor's Map/Parcel 141 11111001 (o`t5 L —6ak Ok tk Rb cu ,Mlle Installer's Name,Address,and Tel.No. So$ -411 Designer's Name,Address,and Tel.No. C APEw%Oe.. rv4tx fnsts/R340 Wlr65t4-� 5 3 coM�t�t41 St ee Type of Building: I l Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan. Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) D — 13o X BOA Date last inspected: 20 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea . Signed Date JL 31-IAO I i Application Approved by Date ( r Application Disapproved by r Date for the following reasons Permit No. Date Issued —� W ;; e No. � Y0 7 „4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for VspoBal 6pstem Construction Permit Application for a Permit to"Construct( ) Repair( ' Upgrade( ) Abandon( ) ❑Complete System ]Individual Components Location Address or Lot No. W 5 Lu w+134trt M i It R,D Owner's Name,Address,and Tel.No. Cer`+TCW�v�11t' ?1-ckvAq �vG�sri.rc r tM X%% s t+tr5onl Assessor's Map/Parcel I H l 119 o a-1 64 -5 L%, 6_I4 IM,i i J �C Vv i t It Installer's Name,Address,and Tel.No. 5C', -`m -&8 1'1 Designer's Name,Address,and Tel.No. C r<IPE�%N tr I ca y�nst3/f�. �` N0A S 3 Curo�w�«,4i S�. iMrE.y'ttcPC�, Type of Building: Dwelling No.of Bedrooms s Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IAI ITgpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. v Description of Soil Nature of Repairs or Alterations(Answer when applicable) ' !"?,e , e �r�[e tivte+A\ r Date last inspected: 0 1 + Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in , accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date (�." �/� ©1 Application Approved by Date / Application Disapproved by / Date for the following reasons Permit No. 01 Date Issued THE COMMONWEALTH OF MASSACHUSETTS. BARNSTABLE,MASSACHUSETTS Certificate Of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x°) Upgraded( ) Abandoned( )by (A a E t>J�� V-n'+'tt (Li s t X/R oo at (o4 s luwtt-A Miii RD ( eti�c 1p.vr�F@ has been constructed in accordance _ �t` P 7 " with the provisions of Title 5 and the for Disposal System Construction Permit No. oqffadated Installer etdprL"I 7. 9�Q[ 7Z Designer �' #bedrooms /is' 7"` Approved design-flow A 1 /3 - gpd r mm.1. �'ZI The issuance of this permit shall not be construed as a guarantee that the system will function as.designed. Date 1J� f Inspector . ,r - -- - --- ---------------- 1-------- >- --- --- -- -- - - - -- No ,raj Fr f , Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is herebyanted to Construct Re granted ( ) Repair(/Y) Upgrade( ) Abandon( ) System located at G H 5 Urn[3 e<T YAM Ni). and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be complet ithin three years of the date of this permit. Date ' ;7 l '- Approved by r Commonwealth of Massachusetts / f. � l DbJ Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments S. l Property Addmss Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: ,I key to move your cursor-do not � �� cfT��U� use the return Name of Inspector _ keys a/Z44�iF Y 1�� �gyl. Company Name rf� Company Abdr6ssc- Cityrrown State Ay— Zip Code Qv 8;- 36 c9 5� Z�v Telephone Nu /)/f50�0_ License Number B. Certification 1 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 9-zV—/Z- o 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 Title 5 Offidat lnepec6on Form Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ' / 0R� Owner Owners Name ' t information is required for every / A- page. CitylTown ate 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: W4B) System Conditionally Passes: ❑ e or more system components as described in the"Conditional Pass"section need to be rep or repaired.The system,upon completion of the replacement or repair,as approved by the Boar Health,will pass. Check the box for"ye "no"or"not determined"(Y,N, ND)for the following statements.If"not determined,"please expla The septic tank is metal and over years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltrati or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced "h a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is struc ally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yea Id is available. ❑ Y ❑ N ❑ ND(Explain below): i I l i tsins•t tno Me 5 Offidal Inspection Fomr.Subwdaos Sewage Disposal System•wage 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Formm--Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every `���� CO��t`�- VV4 �u3eL- 3 —�"(Z- page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) +Sj,, B) S stem Conditionally Passes(cont.): ❑ Obsery . n of sewage backup or break out or high static water level in the distribution box due to broken o bstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspectio ' (with approval of Board of Health): ❑ broken pipe( are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is remo d ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of He h): ❑ broken pipe(s)are replaced ❑ Y ❑ N ND(Explain below): ❑ obstruction is removed [IY ❑ N ElN Explain below): C) Furt r Evaluation is Required by the Board of Health: ❑ Conditions 'st which require further evaluation by the Board of Health in order to determine if the system is fa ' to protect public health, safety or the environment. 1. System will pass un Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system i of functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a ce water ❑ Cesspool or privy is within 50 feet of a bordering v ated wetland or a salt marsh t5ins•11110 Title 5 Olfidal Inspection Form:Subsu ge Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every (f�—Rff my, page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) System will fail unless the Board of Health(and Public Water Supplier,if any) Bete Ines that the system is functioning in a manner that protects the public health, safety, d environment: ❑ The s tem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su water supply or tributary to a surface water supply. ❑ The system a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se is tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S 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, perfo d at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of am nia nitrogen and nitrate nitrogen is equal to or less than 5 pprn,provided that no other failure criteria ar riggered.A copy of the analysis must be attached to this form. 3. Other: b) 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 ❑ [N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑*,/,t� Nq Liquid depth in cesspool is less than 6"below invert or available volume is less 'F� than'/Z day flow t5ins•11110 Title 5 official Inspection For c 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 Property AddressC� Owner Owners Name information is required for every page. Cityfrowd 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. ❑ M/a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ O/a. Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ u/4 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. N/4 E) Lar Systems: To be considered a large system the system must serve a facility with a desig ow of 10,000 gpd to 15,000 gpd. For large sys ms,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Se n D. Yes No ❑ ❑ the syste is within 400 feet of a surface drinking water supply ❑ ❑ the system is withi 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zon f a public water supply well If you have answered"yes"to any question in Section E the sy is considered a significant threat, or answered"yes"in Section D above the large system has failed. owner or operator of any large system considered a significant threat under Section E or failed under S 'on D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should cunt the appropriate regional office of the Department. t5ins•11110 Title 5 Olfidal 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 ��� Lll►'Vl�str -�U�l t t_��-� Property Address Owner Owners Name information is required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? �] ❑ Was the site inspected for signs of break out? (� ❑ Were all system components,t e 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 th Soil Absorption System(SAS)on,t�ie site has been determined based on(�tZ11 �Q�wJ� tf,�rtvn!/l ❑ Existing information.For example,a plan at the Board of Health.. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is.unacceptable).(310 CMR 15.302(5)) D. System Information Residential Flow conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 33D DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Title 5 Official Inspection Form Subsurface$ewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments ' �6,-A �2W t f,_ 2k Property Address Owner Owners Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: �_ / A D U D S � 5' L I `� 3 � c��c�`�/2 S�-�l_dfav►1,d Number of current residents: 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: t'• OOU /7 ood = G�Sd- ao�o Sump pump? ❑ Yes ( No Last date of occupancy: Date ti tJ/4 Commerciallindustrial Flow Conditions: Type of Establishm Design flow(based on 310 CMR 15.2 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•11110 Title 5 Olfidal Inspection Fom[Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts WSHIM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every G t Lm- page.. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) W4, Las f occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: k Was system pumped as part of the inspection? ❑ Yes, No If yes,volume pumped: �A, 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/Altemative 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): tsins•11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageL,Disposal System Form-Not for Voluntary Assessments Property Address Z� s Owner Owner's Name infonnaUon is t,trc.6 MA- 4Z1,3Z 3 -29 —I Z required for every i page_ Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: �` tr �g A� 4-99 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑other(explain): 11 Z S 4,—t w 4/ .Qv ✓✓�c e Distance from private water supply well or suction line: feet Y (- Comments(on condition of jofts,(enting,evidence of leakage,etc.): (47&1 .as) (nee l Septic Tank(locate on site plan): Depth below grade: feet `f, �luc C wt -z.�Y[.i2V5 Material of construction: 6 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 �% X p...�"•Xs"_rl` .� ODD Dimensions: —(U A� `�� Sludge depth: 15ins•11N0 Title 5 Otfldal Inspection Form:Subsurface Sewage Disposal System-Pep 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64!5— Luyyi q R tc-c!—?v Property Address yU(QQ Owner Owner's Name ^- information is (t_Lc� "�wt d�3'L 3 -Z-9 '—tZ required for every page. Citylrown 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 ` a 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 How were dimensions determined? (' I� Comments(Ppump g recor`�imjndati— omens�it and`otltfe te�or baffle condition, s*al-rhtegrity, liquid level as lated to outlet invert,evidence c e of leakage,eakage, etc.): . VIA Gr se Trap(locate on site plan): Depth be grade: feet Material of constru n. ❑concrete ❑meta ❑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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �L Owner owner's Name information is G�2�V L LL required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liglji evels as related to outlet invert,evidence of leakage,etc.): VfA. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth belo rade: Material of cons lion: ❑concrete etal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: allons per day Alarm present: ❑ es ❑ No Alarm level: Alarm in rking 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 15ins•11/10 Me 5 Offidal Inspection Fo=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 Property Address ^ o Owner Owner's Name l� information is every . �v v required for every page. Citylrown 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 abovq,00utle " vert �l ( CA Comments(note if box is Ibvel a� distribution to ou�tf9 equal,any evidence Aolids carryover,any evid nce of leakage into or 00 of box,etc.): '04 Pu Chamber(locate on site plan): Pumps in working o ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chambe�condifio �umps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): SAS 4*located, explain why:✓ r apt,•�livt S wt 2jWtu ba jVwl c V c-uVe-Y- vacs. . 32%elaz ✓e. tsns•11110 Title 6 Offidal Inspection Form:Subsurfaoe Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addresses p Owner Owner's Name y� information is �f LLC 4- l2 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ?f leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(�c)condi' of s I,Sig of hy�uli�_ilure,levgl o�onding,d��s�o�l,condition`e a,�ou�p v etation, ("�:?►) - i �Y1 1 7VVWk&'1 (�1�• 6P cZ 4 a�54,xc-ajvu�,1-L :Q t"t`' 4t a- (6 ;mod d/4- C ools(cesspool must be pumped as part of inspection)(locate on site plan): Number and c uration Depth—top of liquid to in e ' ert Depth of solids layer Depth of scum.layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes�Not5ins•11ho Title 5 Offidal Inspection Form Subsurface Sewage7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C2d� Lun1c3&�-�1�llt t.�-�9 Property Address GO� Owner Owner's Name information is / e���C�►� yVl.._,LW— lA A— required for every C� page. Citylrown 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, L etc.): N/a Privy(locate on site plan): Materials of constructioTt. Dimensions Depth of solids Comments (note condition of soil,.signs of hydraulic failure, lev onding,condition of vegetation, etc.): t5ins•11/10 Tile 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 Property Address / Owner Owner's Name n,, information is required for every State Zip Code Date of Inspection page. Cityftbwn 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 1)s6s �TU t� 3•�'�- Q (-9 �- `,pry. MS 4,-3 23.D' 9-4 -W-o, rr t - - -f - — — - t5lns•11/10 Title 5 015dal inspection Fan Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not four Voluntary Assessments &46- L.UwtQir-�— MtLt-- +Y/ Property Address Owner Owners Name information is —&,"-jZW-VLLLC 414- required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exa Check Slope Surface water 1'� `� "� �'— ""` 'c Po "- eCLV- Cg/Check cellar �v <JL- Shallow wells YvvY( Y-4�P—✓d-I z / Estimated depth to high ground water. feet I Please indicate all methods used to determine the high ground water elevation: Q Obtained from system design plans on record If checked,date of design plan reviewed: pate Observed site(abutting property/observation hole within 150 feet of SAS) �^4 � ry2�E eqlk Checked with local Board of Health-explain: jvp�0��n ` 1 Lf;(A/Il+- t Lc o rU 1:4 L-L-r— -[ Q ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: '� � •r g-zY f a , . �a r• / Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Submafaee Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments (..0 r� �4 tLL.'�,� Property Address I t_f Owner Owners Name !�/ information is Z&JIMV( LL&0,- / �16 3-2-- 3_�9 (Z- required for every 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-11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 17 of 17 I AsBuilt Page 1 of 1 � tL 4t & lq7- /i y 4z"l LOCATION SEWAGE PERMIT NO.. VI LLAG E I N S T A LLER'S NAME i ADDRESS R U I L Of R OR OWN ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED k0T L 7 lL 33 -�3 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=147119001&seq=1 3/21/2012 Aloo-fie I/ (V'r �S. iv7- N LOCATION SEWAGE PERMIT NO 6,S A,o os-f Gist T A -51Y,9 VILLAGE INSTA LLER'S NAME i ADDRESS I U 1 L D E R OR OWN ER DATE PERMIT ' ISSUED Z of DATE COMPLIANCE ISSUED ?5 ko i 6 7 . T12p Al i I ' r)K3� �3 �s H"// /ZC+ No.... s- � ` ....�. .��� Fim... ........... — THE COMMONWEALTH OF MASSACHUSETTS �Q BOAR® OF HEALTH / OF............................ ......................................................... Appliratiun for Uiipusal Works Cfinstrnrtiun rermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......... . ...... 1zTs.-----Z�-4-------'- ............................................................... _ O n or Lot No. ..`n`/ .r 1�.��✓JI U.P�!.r .! -•-�/=�r••-•.. �.v...J �`Jf�UU�I1���j ....._.... _Owner l Address •---------•--- 1L.1-.._.l.Y.s ../..........� ls .. < -/.... Installer/ Address p dType of Building Size Lot... ?. _ .Eq. feet U Dwelling—No. of Bedroom s......... .Expansion Attic ( ) Garbage Grinder ( ) �+ Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) f4 Other fixtures .----•-•--•••-•-•--•--•-•..---•• W Design Flow............................................gallons per person per day. Total daily flow......... 3. ...................gallons. WSeptic Tank—Liquid*capacity/j�V..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing qm �� O Percolation Test Results Performed by...__.-,L........t.._...............��........................ Date-__- ._._�/ .__ ... 14 Test Pit No. 1------- minutes per inch Depth of Test Pit.................... Depth to ground water.......... ...... f=, Test Pit No. 2 `-minutes per inch Depth of Test Pit.................... Depth to ground water......... ......� ODescription of Soil.................................................. 3'/ -_._�. �....---•--••--.-•--------••.--•---•--'---'-•-- x V ----------------------- -------------------------------------------------- .........---------.-----------•-•-----------..._.. ...------ ---------------------------------------------------------- ------------------------------------------------------------------------------•--------'--•-----•---------------------------------------------------•-'------•-----------------------------•----•---••.. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in,accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not.to place the system in otio it a Ce ifi f o ce has been issued by he board of Te g ..............!u / GG Da ApplicationApproved By............... •• -- .t-•.. ............•------'---•----'---•-••----...................• --s•... .......�..... D e Application Disapproved for the f ll wing reasons-------------•---------'---------•----------------------•-----'------------------'•-----•----••--.........._..._ ---------------------------••----•-----•-••--•-•...-•---••--------•-•-•--'-------'-----....................--------•--•--•---.---------------•-•------.................................................. Date PermitNo......................................................... Issued....................................................... Date No................_....... FEic............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF............................................. ......................................... Appliratioai for Disposaloxko Cnottotrurtion rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Add r ss ,7 1 or Lot No. .....,. ...,1 y ......� 1............................. W - Owner / Address Instal er Address q Q Type of Building Size Lot._ ..1_�.e..."Sq. feet aDwelling—No. of Bedrooms._._._...................•....__....Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 0.1 Other fixtures ...--•------------------------------------------------.•••--•-•••••••••--••••••-••........•••••••-••••-•••-••-•-•-••---•-•••••-•-.....__..._......••-• Q gallons per person per day. Total daily flow__.____._ ....................gallons. W Design Flow............................................g � P P P Y. y ��.L� WSeptic Tank—Liquid capacity/Vn_9 ..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit I o--------------------- Diameter-•-•--_.___________- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) _ ~' Percolation Test Results Performed by �.............•-.-._..__._ Date.__�Yat Test Pit No. 1................minutes per inch Depth of Test Pit.___ _....__....__ Depth to ground r____-----_ Gi, Test Pit No. 1,94p#gminutes per inch Depth of Test Pit. Depth to ground water... a ............................................... D Description of Soil -�r Uc' ............................................................. x W U Nature of Repairs or A)terations—Answer when applicable................................................................................................ -----------------------------------••----------...------•--•------------.........._......--------------------------------------------------------------•---------•-----.....-•-•-••---•...-•-•----.-••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ^ oo ,ltio til a C tifi of Co iance has been issued by jhe board of h � �✓�'' Signe . --.•! r' - ---- Da Application Approved By..-•-••_.--•-•••• •-• /� -- -----•- ---•--------------•------------------•--•----.------ .... .• - ) _ D e 3 Application Disapproved for the f ll wing reasons-..............................-.......................................... ....................................... ............................................................ ----•••••---•---•-.............••••--............................---•-----•-•-----•-----•••--••••-••--•••-•------...- ......•-••••---- Date PermitNo......................:....................•----•----•--- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.............................................. 01rrtifiratr of Tooipfiaitrr THIS IS TO CERTIFY, That the Individual Sewa e Disposal S stem constructed ((/ ) or Repaired ( ) efd4---------------------------------- Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- d-ated._.............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION—SATISFACTORY. DATE.............. .�a�.........--•••.......................... Inspector..-------•-.•----••-- \ THE COMMONWEALTH OF MASSACHUSETTS 55-L4—j4 _ BQARRD.:.OF HEALTH � No........................� s FEE........................ Disposal Works ono"' , Vrrmit Permission is hereby granted.......................... A0 ----•-••-- ' NM I.......................... �c� o to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street <l as shown on.the application for Disposal Works Construction Permit No....... .......... Dated.......................................... .i..n . _ _ ..- - r ....................•-••-------- Board of Flealth DATE_......... �'' �C3�----•-•--•------------------------------- FORM 1255 A. M. SULKIN, INC., BOSTON syrg�yprnt�O�3/l�a�tl�fpL�r. kVd,'P.1 � ±:, S . �, •---�-�-,-.,.,,-�,,. ._:_.. 1 Cp ,/� -ate '4^, ,� t" w ; ` r ww Rr % a<( Z •�"-t r rd,14,< s yr nglla`y ft+ ✓?4t,�1= r, fy—'r•" n � k.-„ 3Ai' .�, q t .�N A vii�* e /� A, t t ° r I a u G a .- C ♦4v p*7 �} �r '�i.� 5 4,;/ �•�(11�1' _ `'\ �J�xh� } cC,. e up j. ! :;� �.t {' /�,- ane� ,d ! �C_e x k •g } ; y , Yi�M`' '`, r yt'q' '� yi� 'e J(t.. r�g r3 kr+�. �,1 •,p .'� IN `� � sr..a,s`��� 't e�� 5 ,� °i � � � ••,F s �1., � � � _1'�, �r' :i r,s� r.,� � .� 1 '1 � ,l tl, .:.,,. # e.r�a tw r .�, i$�r.''a`., i:.� 3 -•' ..: .:_ , 1 _._� �l f I .e;,,ls,-r� '3�� rr M. x' -r I r.e..: T j ,$ �, p !'v r i ~,.. �, •Y4 '�f r z 4 i a:/ r x. � 1 f �,af wt ` �jl 1 , �. ' �'`Y fi'✓'r' e 0 !� ,/ .�./,'. C,'� tr hit Z , r, ��. 72 ti I t�v / \`re { _ ft 1+ l ±.. L a \i:..�lr' T a,+"�'�z tp "q � f m .� s c ♦ I ) _.y � �, "' + 3 A jam, � C � � 'e5 �` ��k x a, !rIAA .. 1. �. OF =a u " ( o IORSE { 3 zi p ++s s rr f . /�''oaru 6+ r . . LJ) i� u y ?� }f K> y r{ W' C�y1` I /'Y6s✓ Gl� �I f A 1IA. L �0 a I G f r s { x r 20FSS/0NAL nnr �t s � T IN I k'SPOT' .ELEVATION : lr ,sl..E '� �i`II l <CONT®UR.--- ® :- -D CERTIFIED PLOT PLAN, z ¢ -"I~V,SPOT ELEVATION. ATUM � i431 " ,j • , C®N'TOU 0 w. G T 9 /T y t .1 �rThe; location of any. existing under ound $ewe,xage, , ' s;{ orother uta.lties`shown' on trisp�an is approx- IN � 1h y p da zt T?d S b z a l a e* o iy asp determined from r, --- .s and:/or venial° ��, in ac rlmat�on k'Ttie contractor �s responsible tfor the ' , v xcaz ,on. of,Athe :existing locations t gin; the .fzeld. 411 SCALE, /" —46) DATE J' 3, yr 5• � �E e'�`111NO,EERh�IIe:�CC►� BA6 . CLIENT;- GI �� . , }, I CERTIFY THAT THE ,.PR0POSEDj�.� �t31�TERE RIEtiI fTE>?$ED J0�`NO. o 1---- .BUILDING SHOWN ON THIS PL AFJ n4� VIL �` L�1Np _ t '" OR GY CONFORMS TO THE' ZONING LAWS Nfl. NER b RV x" r ! 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