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HomeMy WebLinkAbout0454 MAIN STREET (CENT.) - Health (2) 454 Main Street Centerville A= 208 - 132 UPC 12534 .2-15m fin � IN �, 1 Cr��� � ° R°"�� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsISO ' 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owners Name ; information is required for every Centerville MA 02632 5-9-19 '' lip 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. Important:When ti A. Inspector Information filling out forms p �S•y��P,..••• .. s`S'9�i,% on the computer, O?= cyG use only the tab James D.Sears ? :' JAMES :N? key to move your Name of Inspector 9 v SEARS cursor-do not Capewide Enterprises *' use the return a' o key. Company Name ?� rT"t��rli=l�-o`�•r 153 Commercial Street IG� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 51623 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 5-9-19 lapector'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.2612018 Title S 015ofal inspection Forth:Subsurface Sewage Disposal System-Pegs 1 of 18 OZ a5ed xej dH t7b:E1, 61,0Z 56 AeW Commonwealth of Massachusetts Title 5 official Inspection Form r Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 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 1500 Gal.Tank D Box and two pits 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): t5tnsp.doe•rev.7,2612018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Pape 2 of 18 l,Z a5ed xeJ dH tib 6 Me 96 42W Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street (Right Side System) L Property Address Bruce Kennedy Owner owner's Name information is required for every Centerville MA 02632 5-9-19 Pap- City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) 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): Pe ( Pp ) ❑ 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 pumpingmore than 4 times a year due to broken or obstructedpipe(s). The Y 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 functloning In a manner which will protect public health, safety and the environment: 5insp.doc•rev.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 ZZ a5ed xe:1 dH Sb£6 ME 5l, AeW Commonwealth of Massachusetts uFTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is Centerville required for every MA 02632 5-9-19 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 feel 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.7126f2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page4 of 18 62 a5ed xe:1 dH 5,V:£6 61,02 96 AeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments ,y 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name reformation is every Centerville equiredforeve MA 02632 5-9-19 page, Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cost.) 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 eteelip as is less than 6"below invert or available volume is less than 1/Z day flow P/r'rs ❑ ® 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 fai s. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure, 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is withln 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 15insp.doc•rev.7126/2018 Title 5 Offidsl Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 �Z a6ed xeJ dH 91V£6 6 60Z 91, AeW Commonwealth of Massachusetts Title 5 official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15,304.The system owner should contact the appropriate regional office of the Department. 6. You must Indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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)) 151nsp.doc•rev.712512018 Tltla 5 Official.nspection Form:6uMurface Sewage Disposal System•Page 6 of 1e qZ abed x2J dH Lt,:El, ME 91, 42W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owners Name Information is Centerville required for everyMA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Toth Both Number of bedrooms(actual): 7 Systems 9 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 990 Description: 1500 Gal. Tank D Box and two pit's Number of current residents: 2 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2017-162,OOOGal Detail: 2018-137,OOOGal's 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 9Z abed xed dH Lt,:£6 61.02 5l, AeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner owner's Name requinform r on is Centerville MA 02632 5-9-19 requiredd far every Page. Cityfrown 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: 15insp.doc-rev.712812018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Pape 8 of 18 LZ a6ed xed dH 8-V:E 6 61.0Z 91, AeW Commonwealth of Massachusetts Title 5 official Inspection Form c Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments .y 454 Main Street (Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 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: 1994 Permit #94-411. 8-2016 New D Box. II Were sewage odors detected when arriving at the site? Ye❑ s ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"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.): Pipeing is 4" PVC SCH 40. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 92 a5ed xed dH gb:EL 660Z 91• AeW Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 454 Main Street(Right Side System) Property Address Bruce Kennedy Oamer Owners Name information is required for every Centerville MA 02632 5-91-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: . 11 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. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1" 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 17" 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 and covers at 11" below grade. In tee outlet baffle. No sign of leakage or over loading. tSInsp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposel System•Page 10 of 18 6E abed xed dH 6-�:£l, 6 60Z 9 6 AeW Commonwealth of Massachusetts 1. ,A Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street (Right Side System) Property Address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 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 t6iup.doc rev.7262016 Tile 50ficial Inspection Form:Subscrlace Sewage Disposal system•page 1t of 18 06 a6ed xed dH 6t,:El, 660Z 91• XeW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments L•� 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owners Name information is Centerville required for every MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) 8. Tight or Holding Tank(coat.) 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"-2'below grade wltwo lines out Box is new 8-2016 wlcover at 6" t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 6£ a6ed xed dH 61V:£� 660Z 51• X2W Commonwealth of Massachusetts o Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t7l� 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why, Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ inn ovative/a Item ative system Type/name of technology: t5insp,doc-rev.TM)2018 Title 50fflcial Inspection Form:Subsurface Sewage,Disposal System•Page 13 of 18 Z£ a5ed xej dH 61V:£6 660Z 5l AeW Commonwealth of Massachusetts ,P Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owners Name requir reqtkinuired is Centerville MA 02632 5-9-19 required for every 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 two 1000 Gal. Precast pits. Pit#1 pit at 30" below grade w/cover at 8'. Pit is dry,clean wall's like new. Pit#2 at 26" below grade 6"water. 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.): t5lnsp.doc•rev.712&2018 Title 5 OMciai nspection Form:Subsurface Sewage Olsposat system•Page 14 of 16 E£ a5ed xezi dH 09:E l, 61.0E 91, AeW F Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp,doc•rev.7126r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 16 {,E a5ed xed dH 09:E 6 6 XZ 9 6 4eW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 15insp.doc•rev.7/26I2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 5£ abed xe:1 did 05:£6 6 60Z 91, AeW May Cl 19, 12:10p Capewide Enterprises 508-477-4977 p,5 Aug 14 2016 1*20 4m The fnspec Man 508W9919 page 34 CD cp 4- CL *14 ;T W M V; w ' 96 a5ed xe� dH 09: 6 ME 5L 42W ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��. 454 Main Street(Right Side System) Property Address -- Bruce Kennedy Owner Owner's Name information is Centerville required for every MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 1W Estimated depth tcl('h�h ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ck area and abulting property. 12'+ no G W Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.M612016 Title 5 OfTidel Inspecdon Form:Subsurface Sewage Damsel System-Page 17 of 18 LE a5ed xe:1 dH 1•9:E 6 6 60Z 91, AeW - Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t; 454 Main Street(Right Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1,2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r--�I)DZ ,6o aM t5insp.doc-rev.V26018 Tiee 5 Official Irtspection Form:Subsurface Sewage Disposal System-Page 18 of 18 g£ a5ed xed did i 9:6 6 6 60Z 9 6 AeW May 15 2019 13,38 HP Fax page 1 a09 /3c2__, Commonwealth of Massachusetts 1? Title 5 Official Inspection Form 4 r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,' r.� 454 Main Street( Left Side System) Property Address Bruce Kennedy Owner Owner's Name information is : required for every Centerville MA 02632 5-9-19 01 page. 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. In$ ctor Information filling out forms Pe 18830on the computer, f-N,,- � p.. use only the tab James D. Sears : JAM E S o s key to move your Name of Inspector — st3: :Cn= cursor-do not Ca wide Enterprises use the return : �'• �+ p key. Company Name 153 Commercial Street �o,F s'4i4 —Idl Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 inspecled 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 5-9-19 :rnspector'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. tSlnsp.doc•ray.712&2018 Tide S ONcial Inspection Fora:Subsurface Sewage Disposal system•Page 1 at 16 May 15 2019 13:38 HP Fax page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F _454 Main Street( Left Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page• city/Town state Zip Code Data 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): 15inap.doc rev.7126[2018 Title 5 Official Inspection Form!Subsurface Sewage Disposal Syatem•Page 2 of 18 May 15 2019 13:38 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1' 454 Main Street Left Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. Cityrrown 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): 0 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: t5lnsp.doc-rev.72612018 Tale 5 Olficlal Irispedion Form:Subsurface Sewage Disposal System-Page 3 or 16 May 15 2019 1338 HP Fax page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street( Left Side System) Property Address Bruce Kennedy Owner owner's Name required for is 7 Centerville required for eve MA 02632 5-9-1 9 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 fall 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. I . ❑ 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 t5mp.doc•re+.7/26/2018 Tide 5 official InspecWn Form:Subswface sews a Dia aal 9 po System•Paga 4 W 18 May 15 2019 13,38 HP Fax page 5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Left Side System) v Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 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 emmgwsl is less than 6" below invert or available volume is less than Y2 day flow Por— ❑ z Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s , Number of times pumped: PP ( ) P P ❑ ® 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 t5inap.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 May 15 2019 1339 HP Fax page 6 c 'y Commonwealth of Massachusetts vwlTitle 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Left Side System) Property Address Bruce Kennedy Owner Owners Name information Is required for every Centerville MA 02632 5-9.19 page. CitylTcvm State Zip Code Date of Inspection C. Inspection Summary (conq If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all Inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ 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)] t6lnsp.doc rev.7126/2018 Title 6 Official Inspecdoo Form:subsurface sewage Disposal System-Page 6 or is May 15 2019 13:40 HP Fax page 7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street( Left Side System) Property address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 page. CitylfDwn State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Total Both Number of bedrooms (actual): 7 System 9 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 990 Description: 1000 Gal.Tank D Box and pit. Number of current residents: 2 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)); 2017-162,000Ga Detail: 2018-137,000Gal Sump pump? ❑ Yes ® No Last date of occupancy: present Date t5irisp.doc-rev.7/25/2018 rile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 or 16 May 1.5 2019 13:40 HP Fax page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e M v, 454 Main Street(Left Side System) Property Address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 page. C4/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.72612018 Tide 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 18 May 15 2019 13:41 HP Fax page 9 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 454 Main Street(Left Side System) Property Address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 page. Citylrown 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: 1994 Permit#94-411 New D Box 8-2016. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 28" 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.); Pipeing is 4" PVC SCH 40. t5insp.doc-rev.W26J2018 Title 5 Oficial Inspection Form:Subsurface Seviage Olsposo System•Page 9 of 18 May 15 2019 13:41 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v„ 454 Main Street ( Left Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) B. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is a confirmed b age y a Certificate of Compliance. (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 0.1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 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 and cover's at 18"below grade, In and outlet tee's. No sign of leakage or over loading. 15insp.doc•rev.712612018 Title 5 016cial Inspection Form:Subsurface Sewage Disposal Sysmm-Page 10 of 18 May 1.5 2019 13:41 HP Fax page 11 Commonwealth of Massachusetts ,iq Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �4 �� 454 Main Street Left Side System) Te Property Address Bruce Kennedy Owner Owner's Name information is Centerville MA 02532 5-9-19 required for every 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 um in ; P P 9 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 y El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.712612 0 1 8 Title 5 Official Inspection Forth:SubsLeace Sewage Disposal System-Page 11 of 19 May 15 2019 13:42 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 454 Main Street( Left Side System) Property Address Bruce Kennedy Owner Owners Name information is required for every Centerville MA 02632 5-9-19 page. City/Town State Zlp 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"-28" Below grade wfone line out. Box is New 8-2016 Wlcover at 6". t5insp.doc-rev.7/2612018 TWe 5 Official Inspection Form:SLbsurface Sewage Disposal System•Page 12 of 18 May 1.5 2019 13:42 HP Fax page 13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street( Left Side System) Property Address Bruce Kennedy Owner Owner's Name required for is Centerville MA 02632 5-9-19 required for every page, CityfTown State Zlp Code Date of Inspection D. System Information (cunt.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located explain why: Type: ® leaching pits number: 1 ❑ 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.7/2612 0 1 8 TIVe 5 011dat Inspection Form:Subsurface sewage Disposal System-Page 13 of 18 May 15 2019 13:42 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 454 Main Street (Left Side System) Property Address Bruce Kennedy Owner Owner's Name required fo is every Centerville required for eve MA 02632 5-9-19 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 22' below grade. Pit is dry w/no high stain line.Wlstain line at 2'off bottom. 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.): 15lnsp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage oisposal Syslem•Page 14 of 18 May 15 2019 13:42 HP Fax page 15 Commonwealth of Massachusetts .U10Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 454 Main Street (Left Side System) Property Address Bruce Kennedy Owner Owner's Name intimation is required for every Centerville MA 02632 5-9-19 page. CitylTown 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,): Nnsp doc rev.7MJ20IS Title 5 Official inspection Form:Sobeurface Sewage Disposal System-Page 15 of 1S May 1.5 2019 13:42 HP Fax page 16 c Commonwealth of Massachusetts Ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Bruce Kennedy Owner Owner's Name requinform r on is Centerville MA 02632 5-9-19 requiredd for every 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 I 15insp,doc•rev.7/2612018 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 May 15 2019 13:43 HP Fax page 17 57' ,l, �Fr C'£NT s%S/4p+ ,c �+ ✓__ ----------------------- 0 13 QA 4/5" o �' s � M O � 0L� Zrj l May 15 2019 13:43 HP Fax page 18 y. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �7 v, 454 Main Street Left Side System) Property Address Bruce Kennedy Owner Owners Name information Is required for every Centerville MA 02632 5-9-19 page. City/Town Stele Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water . ❑ Check cellar ❑ Shallow wells /vo Estimated depth t high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation; Ck area and abuting property12'+ no G.W.- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-fev.7126/2018 Title 5 CMciaj Inspection Force:Subsurface a Disposal�`a9 Po Systa,n-Page 17 of 18 < May 15 2019 13:44 HP Fax page 19 - Commonwealth of Massachusetts VF U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street(Left Side System) Property Address Bruce Kennedy Owner Owner's Name information is required for every Centerville MA 02632 5-9-19 page. CitytTown 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: TightlHolding 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 GRAAi Ip97 mA /•�, --------------- 151nsp.doc•rev.712612018 Title 5 0mcial Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYiratiou for Misposai *pstrm Construction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System )�Individual Components Location Address or Lot No. ifS4 MA(o S-i �'��( Owner's Name,Address,and Tel.No. LA IJDA 4 TkoNAC? KAjt ' Assessor's Map/Parcel 0�0� L,-ft kAW 5-i Cf)TT6_kYf4425' Installer's Name,Address,and Tel.No. $$OR-477-2r&1'7? Designer's Name,Address,and Tel.No. CAPeujitpe (.5 S� . p Type of Building: Dwelling No.of Bedrooms /" 0- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 124E&tx�, ( l A{, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revisio Kte Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ZW 574 IIJ&4) U_80K Ri 6WZ pivpaN S cb- SysTE.A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Si Date Go — ` `� 0 Application Approved by Date $ I Application Disapproved by Date for the following reasons Permit No. C;W(0 � �.� Date Issued r -- -- -- --ter• --------------- ____------------ No. C7`t/ lf' '�p`� Fee 'THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pphcation for Vsposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System 9 Individual Components Location Address or Lot No. i f S14 MA(O $( 1ctt[/aj5 Owner's Name Address and Tel.No. Assessor's Map/Parcel aOS- ( ;Z. 454 MAW ,ST G6lJT6_kV(44J:5_ Installer's Name,Address,and Tel.No. 502—47?"2Q"77 Designer's Name,Address,and Tel.No. CAPewiDC LL4- 1S ST- N,4S61Pi9 N/A Type of Building: / Dwelling No.of Bedrooms ►`�(J/' '!- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building PIES(01_�t 144 , No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) Allgpd Design flow provided gpd 1 Plan Date Number of sheets Revision Date i Title Size of Septic Tank Type of S.A.S. ,t Description of Soili 1 Nature of Repairs or Alterations(Answer when applicable) 5--w , I J&& 0 - Rle�4� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Sine Date Application Approved by Date Application Disapproved by Date for the following reasons i Permit No. C;�10/(p Date Issued 1 --------------------------------------------------------------------------------------------------------------------------------------- d x� y�Y ouf+�, S,vp THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS certificate of Compliance THIS IS TO YERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by CA)L;A blv L-4-r, at qS(4 A{A I &J- 5T e t V i L4E (RT)_ has been constructed in accordance- with the provisions of Title 5 and the for Disposal System Construction Permit No. _a/6 ',,?P dated Installer N (A , �Qom)/j,L �=�7��r�s �-�--� Designer �" #bedrooms�� .� Approved design flo //� and The issuance of his ermit s all of be construed as a guarantee that the system will tiio as des d. i Date 1T Inspector S ----------------------------------------------------------------------------- ----------------------------------------`-'------------- No. /& - -o Fee G THE,COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construction j3ermit Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( ) System located at 44SV M41 A.) S—r cQ)ZEy(CL_F_ S(pC X/G74-zi'4 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 in t be completed within three years of the date of thi' permit. Date l� ! 1 1 Approved b /'� No. Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for NspoSal 6pstem Cortstruttion permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ElComplete System ndividual Components Location Address or Lot No.454 #4Ai o ST (V U(ckc— Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel �(�g `�� Ltsq MAIL) S Installer's Name,Address,and Tel.No. 5'0 12 4-7 7—81Z 77 Designer's Name,Address,and Tel.No. &k­�vtrpv 6N-tu hjs'es Ltc WIA (53s s Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 's lAk— No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Rev(Sion Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) J 097)� 06x) D —3o)G 4f C—Z�!r � �t i�� Safes Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board f H Signed Date ` (�11 Application Approved by Date IL Application Disapproved by Date for the following reasons Permit No. �� � Date Issued No. ;t Fee ✓ ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal 6pstem Construction Permit � 1 Application for a Permit to Construct Repair Upgrade Abandon ❑Complete System Individual Components PP ( ) P ) P�' ( ) ( ) P Y P i Location Address or Lot No.45 4 AU,�l N SZ C`U(U_C-: Owner's Name,Address,and Tel.No. LIMPA + 'XD6.4(4A iw(G r Assessor's Map/Parcel ad 8 !3.;►- LfS-q M41U 5T CZYL rt- l U.0 Installer's Name,Address,and Tel.No.To$-4417-9%77 Designer's Name,Address,and Tel.No. Type of Building: ��--- Dwelling No.of Bedrooms V1 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building s MOLT(tA4 . No.of Persons Showers( ) Cafeteria( ) Other Fixtures ""J Design Flow(min.required) l gpd Design flow provided gpd i 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system_in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H B Signed Date Application Approved by Date Application Disapproved by Date for the following reasons t Permit No.T; (n Date Issued ----------------------- - -- ----------------- ------------------------------------------------------------------------------------- �uy L S, de THE COM MONWEALTH OF MASSACHUSETTS / rT( BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(u) Upgraded( ) Abandoned( )by (2A f SEW KXM &-r'mpk <zs LLC ' at__q.S4 "Qt(U $-r C'u i t F has been constructed in accordance 0&5-dated f with the provisions of Title 5 and the for Disposal System Construction Permit Noa. InstallerCAP6(yty--- &4 Qr,4�S Designer #bedrooms Approved design flow gpd The issuance of this permit s all not be construed as a guarantee that the system willffc as d sign f Date Inspector h oo V --------------------------------------------------------------------------------------------------------------------------------------- No.. (Ir " Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( k Upgrade( ) Abandon( ) System located at �00 5710G5:r DE -"�Qa4 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 co leted within three years of the date of this permit. ° Date i 1 � Approved by nig 14 2016 14:15 Jim The Inspector Man 5085349919 page 1 � T %N 'f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments tC'9 ��..'�• 454 Main Street ( Left Side System) Property Address t-+ Ronald Knight Owner Owner's Name information is ill t enerve MA 02632 8-11-16 required for every C t:+ page. City/Town State Zip Code Date of Inspection W 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 v l ' \\\INlllllllrl/ filling out forms , �' SN OF ti/ i2 on the computer, �O .gss�4 use only the tab 1. Inspector: r�?�:• :c'. key to move your JAMES G cursor-do not :2i use the return James D.Sears ke Name of Inspector s y Capewide Enterprises, LLC :{�'•. `moo. Q Company Name ��� 153 Commercial Street �'�U, �SuI N stP\�G,.�`� Company Address Mashpee MA 02649 City/Town State Zip Code 508477-8877 51623 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 'j, 8-12-16 Anspeda��Vrrs 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 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. 15ins.doc-rev.6176 Title 5 Officis Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Aug 14 2016 14:15 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments.- The system is a 1000 Gal Tank D Box and pit O 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): f5ins.doc.rev.6116 Title 6 Official Irlspodlan Form:Subsurface Sewage Disposal System•Page 2 of 17 Aug 14 2016 14:15 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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: i ❑ 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 15ins.doc•rev.SM6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Aug 14 2016 14:15 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owners Name information is MA 02632 8-11-16 required for every Centerville page. CityfTown • 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 I 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 O ® Liquid depth in 41MI011111111 is less than 6" below invert or available volume is less than 1/day flow Pj-r 15ins.doc•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Aug 14 2016 14:15 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 454 Main Street (Left Side System) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (Cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10 000 9pd. El ® y 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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. l5ins.doc•rev.6116 Title 5 Official Inspection Form.Subsurface Sewage Disposal System Page 5 of 17 Aug 14 2016 14:15 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts L Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 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? Z ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Total Systems Bh g Number of bedrooms (actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 990 15ins doc•rev.6/16 Tltle 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 6 of 17 Aug 14 2016 14:16 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Left Side System Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank D Box and pit 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2014-191,000Gal Water meter readings, if available (last 2 years usage (gpd)): 2015-384,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personslsq.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.doc-rev.U16 Title 5 Dificial Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Aug 14 2016 14:16 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street (Left Side System) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityrrown 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: 2013-2015 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): 15ina.doc•rev.6116 Title 5 Official Inspeclion Form:Subsurface Sewage Dispose'System•Page 8 of 17 Aug 14 2016 14:16 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vt 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every p page. Cityrrown State Zip Code gate of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1994 Permit# 94-411 New D Box 8-2016. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 18" 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 '1 Sludge depth: 2" 15ins_tloc.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 9 of 17 Aug 14 2016 14:16 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is required for every CentervilleMA 02632 8-11-16 page. CityfFown State Zip Code Dale of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8 a 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 and covers at 18" below grade. In and outlet tees. No sign of leakage or overloading. Y j 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.doc•rev U16 'Title 6 Officlal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Aug 14 2016 14:16 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form W 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every A' page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r r C Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): t` Depth below grade: Material of construction: "r ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 3 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 y Comments (condition of alarm and float switches, etc.). "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 16ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 e w i Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 454 Main Street ( Left Side System) t Property Address Ronald Knight - a Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. Cityrrown Stale 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.): / D Box is 16 x16 -28 Below grade w/one line out Box is New 8-2016 w cover at 6". z Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): i If SAS not located, explain why: 11 f t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System page 12 of 17 Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 13 q Commonwealth,of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owner's Name informrequire for is Centerville MA 02632 B-11-16 required for every page. CitylTown State Zip Code Date or Inspection D. System Information (coat.) 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: 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 22" below grade. Pit is dry wino high stain line. F 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.doc-rev.6116 Title 5 Official Inspection Form:Subsu face Sewage Disposal System-Page 13 or 17 r ,f �l Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts 5Official Inspection FormT'tle Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight - Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every 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.): 15ins.doc-rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts P Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 454 Main Street ( Left Side System) Property Address Ronald Knight Owner Owners Name information is required for every Centerville MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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: Lj hand-sketch in the area below ❑ dtawing attached separately I .f t5ins.doc•rev.6116 Tills,5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 j} E Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 16 (FN,TAl v5-T,� Pool - r y o , 3e E; 1-3 ^�= SA - Aug n 14 2016 14:17 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 454 Main Street ( Left Side System) Property Address g Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. City/Town State Zip Code Date of inspection D. System Information (cont.) k Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �N° P 1 g 9 12'+ Estimated depth to hi h round water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: '3 f ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: CK area and abutting property 12'+w/no G.W. seen. q. i f rl Before filing this Inspection Report, please see Report Completeness Checklist on next page. y l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °r 454 Main Street ( Left Side System) _ d Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 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 t i -;a t. Yp 1 t5ins.doc-cev.6116 Title 5 Official Inspection Form:Subsurfsc a Sewage Disposal System•Page 17 of 17 . 'a .'f Aug 14 2016 14:17 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rf 454 Main Street ( Right Side System ) Property Address I Ronald Knight Owner Owners Name information is / �•• required for every Centerville MA 02632 8-11-16 .. page. City/Town State Zip Code Date of Inspection co 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 �+ ��tuUttutUir/// on the computer, ���'�v1'A OF MA use only the tab 1. Inspector: key to move your ?: '• '- cursor-do not James D.SearS JAMES N Al e the return Name of Inspector =�; EARS ke y y Capewide Enterprises LLC 3*' ICI Company Name - `RT1F 153 Commercial Street ' IN Sp�G���Q`�` Company Address t B� Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 8-12-16 ,00rnspector's signature Date ' Y" 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 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. F 15ins.d3c•rev.5116 Title 5 Official Inspection Form:Subsur aoe Sewage Disposal System•Page 1 of 17 Aug 14 2016 .14:17 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal, Tank D Box and two pits. 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.doc•rev.6116 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page Tot 17 s Aug 14 2016 14:18 Jim The Inspector Man 5085349919 page 21 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 454 Main Street ( Right Side System) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 150540c•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Aug 14 2016 14:18 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main-Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. Cityfrown 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 1111111W11111111 is less than 6' below invert or available volume is less than %day fl -5 t5ins.doc rev.W16 Title 5 Official Inspeclion Form;subsurface Sewage Disposal System•Pape 4 of 17 Aug 14 2016 14:18 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Right Side System ) Property Address _Ronald Knight Owner Owner's Name information s Centerville MA 02632 8-11-16 required for every page. Cityrrown 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- 10,0009pd. ❑ ® 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. 15ins.doc•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal system•Page 5 of 17 Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 24 ry Commonwealth of Massachusetts Title* 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r: 454 Main Street ( Right Side System ) Property Address Ronald Knight -- - - Owner Owner's Name information is required for every Centerville MA 02632 6-11-16 page. CityfTown 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? .r ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ElWere as built plans of the system obtained and examined? (if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? T ® ❑ 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: 3 ® ❑ 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: t Number of bedrooms (design): Total Both Systems 9 Number of bedrooms (actual): 7 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 990 y t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syetem•Page 6 of 17 Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and two pits. i 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No 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 OGal Water meter readings, if available last 2 ears usage d 2014-191,O Gal' g ( y g (gp ))' 2015-384,000GaI's Detail: Y. Sump pump? ❑ Yes ® No Present Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: r� t5ins.doc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r` Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 454 Main Street ( Right Side System ) Properly Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. CityFFown State Zip Code Date of Inspection x D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): �t General Information Pumping Records: Source of information: 2013-2015 Was system pumped as part of the inspection? ❑ Yes ® No v 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 ' `s ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•-ev.6116 Title 5 Official Inspection Form.Subsirface Sewage Oisposal System•Pago 8 of 17 Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 454 Main Street ( Right Side System ) - Y Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. City/rown State Zip Code Date of Inspection D. System Information (cost.) I^; Approximate age of all components,date installed (if known) and source of information: 1994 Permit # 94 -411. 8-2016 New D Box �t Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" 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.): R Pipeing is 4" PVC SCH 40 Septic Tank (locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) .r. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gal. Precast H-10 Dimensions: `rr 411 Sludge depth: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 or 17 s Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 454 Main Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name f information is required for every Centerville MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) y. Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" 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 17" �a How were dimensions determined? Asbuit-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.): t1 Tank at working level. Tank and covers at 11 below grade. In tee outlet baffle. No sign of leakage . or over loading 3i iR E lg Grease Trap (locate on site plan): Depth below grade: feet ti Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): '- r Dimensions: Scum thickness Distance from lop 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.doc rev.6116 Title 5 Official Irspection Form:Subsurface Sewage Disposal System•Page 10 of 17 n Aug 14 2016 14:19 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 454 Main Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name information is MA 02632ill Centerville 8-11-16 required for every �! page. Cl State Zip Code Date of Inspection D. System Information (cont.) 1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 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): ;rl 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.): I y; Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5lns.doc•rev.6116 7ille 5 Official Inspection Form:SuOsurface Sewage Disposal System•Page 11 of 17 i Aug 14 2016 14:20 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 454 Main Street ( Right Side System ) Property Address Ronald Knight Owner Owner's Name information is Centerville MA 02632 8-11-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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"-2' below grade w/two lines out. Box is new 8-2016 w/cover at 6". s: 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.): i �i ;j * If pumps or alarms are not in working order, system is a conditional pass. 1 �i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Aug 14 2016 14:20 Jim The Inspector Man 5085349919 page 31 t *O Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments s 454 Main Street ( Right Side System ) Property Address i Ronald Knight a Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 t ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ , overflow cesspool number: ❑ innovative/alternative system Type/name of technology: F. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. Precast Pits. Pit# 1, Pit at 30" below grade w/cover at 8". Pit is dry, clean wall's like new. Pit#2 at 26" below grade Full. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): `I 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.doc-rev.$116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 13 of 17 Aug 14 2016 14:20 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 464 Main Street ( Right Side System) Property Address Ronald Knight Owner owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): `}1 { Privy (locate on site plan): Materials of construction: f1 Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ondin , condition of vegetation, . 9 Y P 9 9 a# etc.): e Y it n: t5ins.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 R. Aug 14 2016 14:20 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b 454 Main Street ( Right Side System) Property Address Ronald Knight owner Owner's Name Information is Centerville MA 02032 8-11-15 required for every ' 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 :1. s� �a ex- I `1 1 r, I tit r f: rj Y1 ;rl s t5ins.doc•rev.6)16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 0117 S ?Ylir ' ''^333�siai:'�'i!`�t' Ys m LO a m 0 0 CL cu En �-- b� r7 r7 47 N � Aug 14 2016 1420 Jim The Inspector Man 5085349919 page 35 f: Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _454 Main Street ( Right Side System ) Property Address Ronald Knight 3 Owner Owners Name »` information is required for every Centerville MA 02632 8-11-16 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 t 'high ground water: 12'+ "I I feet xJ 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) !j ❑ Checked with local Board of Health - explain: . ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: tia You must describe how you established the high ground water elevation: Ck. area and abutting property, 12'+ no G.W.. a� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Tille 5 Official Inspection Form:Subsurfooe Sewage Disposal System•Page 16 0117 p Aug 14 2016 14:20 Jim The'Inspector Man 5085349919 page 36 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 454 Main Street ( Right Side System ) " Property Address Ronald Knight Owner Owner's Name information is required for every Centerville MA 02632 8-11-16 page. Cityfrown 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 ' Y a u G e+ ti ' e"r fw 51 �J &I t5ins.dec rev.6116 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 M I 30.00 THE COMMONWEALTH OF MASSACHUSETTS = BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuu for Dig mial Workii Tunitrurtiun rrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4.54 Main Street Centerville .......................................•---.......-•---•-------...._.._•-................... ....--••••••-•------••-•--.._..---- Location- Address or Lot No. Knight --••--•---•-•-•--•---..........................•------------------••-----•-•--•--•--•--•-••---•- --•-•-•-•-----•-••-••-----•-••---•--•••--•••-----••-•••-•-•-••---•-•-••-•-••••••--------...•-•-•-. W J.P.Macomber Jr. Owner Address Installer Address UType of Building Size Lot............................Sq. feet Dwellingx--No. of Bedrooms------------ _______________________-.___-Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons------3................... Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . d ---------------------------------------------------- . ---- •---... W Design Flow....._......................................gallons per person per day. Total daily flow----_-.-_-______________________-___________gallons. WSeptic Tank—Liquid capacity........___gallons Length................ Width................ Diameter-...------------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length------------_----- Total leaching area....................sq. ft. Seepage Pit No-____-.__-_---.---. Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0­4 Percolation Test Results Performed by.......................................................................... Date--------------......................... 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........................ ...............................•---._....__.....___.....---•--....._._...---•---._._.........------......--------------•---------------........•••-................................................................. 0 Description of Soil......................................................................................................................................................................... W Sand & Gravel W x Omit cesspools . Install 1-1000 gallon U ature �,{ RP airs or Alterations,—An Ave n applicable_______________________ tans -I -a�stribu ion ox -�Ow( � g llon leach pit pit. efts cl................... tside -----------------------------------------=--------------------------------------------------------------------------------------------------------------------------------------------------------••--•. Agr�eWAt--gallon tank 1-distribution box 2-1000 gallon leach pits . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp lia ce has ee issu by the b ar of health. Signed . ...-------- o 7/2 7/9 4, ...... e Application Approved By .:--------------------------- ..... ..........- .. :.....:.... Dm Application Disapproved for the following reasons: ----------------------------------------- ------------------------------------------------------------------------ ..................... . ------------------------------------- ------------------------------ Permit No t":`�'.. 1.:.:.:............._ Issued ................�,�`'. � � Dace NO.Y3.1��...�/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF-BARNSTABLE Appliration for Dirivitial orlt Cno�totror#'tarn [rxutt> , Application.is hereby made for a Permit to Construct ( �) or Repair ( ) an.Individual Sewage Disposal System at: � f 454 *lain.' Street Centerville :,. t . . ................................... �:... -----------•---•-----------•--•---- =-----== ;.-•--•---- Knight Location-Address r 4or Lot No. - ..............._..---•--..-........---------•-••----•---••-+......---- •••=--••`-••-•• ----••-} -'* -• G . r ' Owner 4 'Address t W J P Macomber Jr. ; ..............................•------•-•--...•....-•-------...-•-:Z,--.-----•--...-------------•- ------............ . ....... ;................................................. +� Installer Address Type of Building +'" - - Size Lot q: Dwelling No. of'Bedrooms.__-'_____6__________________________ __Expansion Attic ( .+}), G,'rbage Grinder (f p-I Other Type of Building A.......................... No. of persons------�t------«---------- Showers O — Cafeteria at Other fixtures --------------- ------------- --- • • - Design Flow............................................gallons per person per day..Total daily.flow_._____.__...______..._____....__...........gallons. W y WSeptic Tank—Liquid capacity............gallons Length____________ _ Width....r........... Diameter---------------- Depth........... Z Disposal Trench—No. ............'__.._. Width_._s_`'_-__--__- Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft., " Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by----------- ............................................................... Date..............................=......... , Test Pit No. I----------------minutes per inch Depth of Test Pit--------------------- Depth to,ground,water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.-___A..__ Depth toyground-water.................... _. =---•-•••-•......................................=---------•.---- % D Description of Soil. :....................••---_------------------------------------------=--=-----•------ •-•--------------=--=---- x Sand & Gravel - -• U N ture o Repai s or Alterations,—An we__.____._n ag i__.ble._. ._...._._ ._'_._.. _ _ _____'_..�.... .............,....0© Salton x �,�e Omit cesspools . Install 1-1 tangy if aA.srtr�bution box 1�UUU g ' Ion leach pit plt.l�e tilde, Rsg" s cfe AgrO '--• - ---- ------------------------------------------------------------------•---•-...........--------------------------------- ............................................................. e0nt-.gallon tank 1-distribution 1.px 2-1000- gallon., leach pits . f; The undersigned agrees to install the aforedescribed Individual Sewage:Disposal System.in accordance with the provisions of TITLE 5 of the State Environmental Code—The unde signed-further agrees not to place.the ' system in operation until a Certificate of Complia ce has bee. issued by,the boardfof health. • I '., Signed .:i 44 1 i j 7 2"" 94 Application Approved BY . ............................. - ..✓ Application Disapproved for the following reasons: � _..........(....-------------------- na[e r- � ----------------....-----------------------. >:.......... A .............................. . ------------------------. ---------------- ,. PermN ... ...................._ -/� �� . --- e t` ------ Due ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Er#tftrate of C�omplianre TIhIS,fg60eTJFY J'hat the Individual Sewage Disposal System constructed ( ) or Repaired -- ....... -------................ ....................... ... by ..._......................................_ . -- ... ....... .......... . ........_..._ . 454 Main Street Centerville at ....... ...... - %. _�...... ---------------------. --i--------- has been installed in accordance with the provisions of TITLE-5 of The State-Environmental Code as described in the application for Disposal Works Construction Permit No. --✓....�c �l..f_._.__. dated .` �..,_ _..77o--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE-THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......�. Inspector "' :...` -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �l TOWN OF BARNSTABLE � l - � �o.00 ' . No.....- �......... =a FEE.. .................. Biopoottl orkii Ton',., ion rrmit ` Permission is hereby granted---JP.Macomber Jr.--------------------------------------------•------------------------------------------.;.._..._.. . . to Construct (M ) or Repair ('CX) an Individual Sewage Disposal System 4!D4 ain Street Centerville atNo....................................................................................................... -:f------------------------•--------------- -----------------.._............... - i Street �j as shown on the application for Disposal Works Construction Permit No�__-�"�_��__ Dated_,` _ .:__ . DATE.- ...7 .;..... .................•--- Board of Health # f FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS N cn � Ncn J ui w 0 < a v a � INNV N AA\\ N O Ool ao�o 2 3 2 w Ln \ , OP05ED ��A \\ DDITION �Q OF ti/gs, STEVEN �yG f RUMBA T p Uro SURV�O poj•� i N � O i N BUILDING LOCATION PLAN 3A LOCATION: 454 MAIN 5T., CENTERVILLE, MA 2�9 CLIENT: RONALD KNIGHT SCALE: DATE: DRAWN BY: I " = 50' OG- 14-2005 TMW JOB NUMBER: REVISION: 5HEET NUMBER: 00-050 1 1 CPP-I WELLER *- ASSOCIATES I G45 FALMOUTH RD. -- SUITE 4C P.O. BOX 417 CENTERVILLE, MA 02G32 TEL.; (508) 775-0735 FAX: (508) 775-0754 TOWN OF BARNSTABLE LOCATION � , SEWAGE # VILL.AGECehvC7Z.t/i ASSESSOR'S MAP & LOT-20f 11� INSTALLER'S NAME & PHONE NO. 5-0 A SEPTIC TANK CAPACITY /s00 LEACHING FACILITY:(type) 02 —pp�S (size) 1040 Eck NO. OF BEDROOMS_ RIVATE WELL OR PUBLIC WATER I ll �ss.osj� 6rd7/o'-dam ;. BUILDER OR OWNER NT z or- le DATE PERMIT ISSUED: ®,► 2vI a � rrf �, DATE COMPLIANCE ISSUED: V ARIANCE GRANTED: Yes No Y . I� 1 \ . l / b `�� 5 �) TOWN OF BARNSTABLE LOCATION �/S^�/ �//� ,sue SEWAGE # VILLAGE. ASSESSOR'S MAP & LOT20* INSTALLER'S NAME PHONE NO. �'Y1�C_t�►Yi�iwiZ. s®�, SEPTIC TANK CAPACITY JOOO LEACHING FACILITY:(type)?i }" (size) 1000 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� , �T._.--�.��..`... �� _ Q O �� //�/ // � /�/ y ) I -- I CL Ly I: I, EXISTING I ST 0 TIC S YS TE I I : ( LIMITED I) TO 0 — — _ _ ---- I # 0 F B S _T -- - - - - o -- I - 1 Z I k . , I i -- Z Lwl __ . _ _ _.. . - a , (I 3 If ,. , I I- I . .. _ ` __, I - co J1 f 1 , I ,� f , { J I _I 1 I 1 _I , I I I �I I l� I i l i I I I _ I 1 I :f I I I I I I I � I T I l 1 l I I I I : It r i I �,.I I , , I I I _ I( t II I 1 , ) I, f I I 1 I I I , I I I- I ( I I I I J- I I I I ,I I I I f I I I I 1 i I I I I i r: I, I I I a I I , I,. , - -- _ � I I II I ..: I I 1� I I I I I l I 1 _ J _ _ I . _ I I OL _ I I I -1 _ I I. I _ , _ - I l _ L J1 Ell r I _ I - I I , I I I , I I f J_ I l I ll � I EI' J 2 r 6 r � rJ _ � I f _If _ 341-0r ADDITION l w I G�4T ELEVATION SCALE 1/4r l _0 OtY _jZZwaWW , L ZW SNEET Wcf� < JOB: 0305 :- _. R W B W ._ Y K DATE: 7/0 A/2 5 34'-O' 3'-0" 2'-4't 7'-011 2'-4" ��� TW28�10TW28510 i\/o ry No, i a— _� v o JE I TW28510 ---- — ' o N SrpIN sn�p ILJL.� � � O N m + 1LFL 1 J _ 1 :5 LKNEAD BREAKFAST FAT"i I LY ROO"I o _ IN 22' 0" 21'-0' 13'-8" --1-- f ) REMOVE WINDOWS i I l CREATE PASS TNR UGN CL [F e-= REMOVE WINDOW - CREATE WALK TPROUGN 1 1i -8 1 REPLACE WINDOW W/ ,DOOR - W10x30 STEEL BEAM ABOVE KITCHEN a ;. : , LIVING 1 F` a �- n � u GARAGE 12 E 1,_7 4 -o -- r _ BATH f KEEPING -- W W 1- — W UP a Z OL _ Z F i RST FLOOR FLAN NOTE: SCALE: 114" It-O+' WINDOWS ARE ANDERSEN TILT WASW 400 SERIES Wr SHEET SIMULATED DIVIDED LIGHT MUNTINS AS , JOB: 0305 DRAWN BY: KW - DATE: A/27/05 �.0 , t 34 —0 . s _ u f t ,F F F - - - --- eii �-- i a t t 4 8 3 a I 1_ I f a � 1 f � ItI : �i 7 q, GQNG RETE 1 WA L 8x l0,t 1fF GON INUOU F TING TYP. To I fl�a _ , J I .t I I , i ( i ' I Il , 1 , I i I t � L , fl 1 I I 1 H N cv s. _ I I O ' O I ! a , O l i F i ADDITION FOUI , . AT ON I ,, l 4" CONCRETE Lo r - os _ I _ o _ , . I i f 1 i I � I ; s / r � , I I 3P 2x 10 GIRDER i i 1 3 'i/2F D STEEL COLUMN ` I F F 1 ` ) i � -P�ILGO 30 x30 x1 CONCRETE PAD 2 7 N , 4 SULKAD E I F_ F F _ 5 g all DOOR N1 i - 6 8 i <, EXT. i I tS� t ]8F I ; _._ iI � 1 Ir S A LAYOUT T RT �- _ !I I WITN CORNER R REMOVE EXISTING MATCH EXISTING N G D— ' l T EXCAVATE a- i NO EX BULKHEAD I ` FOR FIRST FLOOR R ACCESS TO EXITING ELEVATION ON BASEMENT Lu m fF n _ DO NOT EXCAVATE V TE I Q BELOW GRAWL SPACE ; s _ I I DEPTH , ' VJ 1 EXISTING XI5T I N G . � _., I: LLI GARAGE CRAWL SPACE EXISTING BASEMENT t1� I Z . Z v 514 EET p FDUN DATION 'LANA,41-011 .- SCALE _ 114111 JOB: 0305 DRAWN BY: KW DATE!. '4/2 7/05