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HomeMy WebLinkAbout0611 MAIN STREET (CENT.) - Health (2) 611 Main Street Centerville A= 207—056 S M E A D No.H163OR UPC 10259 smead.com • Made to USA �C% c Commonwealth of Massachusetts C207- C)T& Title 5 Official Inspection Form lIa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is Centerville✓ MA 02632 11/02/20 required.for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information C)10 on the computer, use only the tab Richard T. Johnson key to move your Name of Inspector cursor-do not D &J Environmental Services use the return Company Name key. 10 Mt. Pleasant Street ay Company Address Plymouth MA 02360 City/Town State Zip Code 508-735-8740 S113545 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 11/02/20 I ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i t cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 611 Main Street `J Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. Citylrown . 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes„ „, no" or not determined" (Y, N, ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form �Ib Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f, 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms noL'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): - I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is withir. 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water ri 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 l5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is Centerville MA 02632 11/02/20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 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: i Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r c� Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is Centerville MA 02632 11/02/20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220GPD Description: 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: N/A Sump pump? ❑ Yes ® No Last date of occupancy: Presently Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �1'. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. CitylTown 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 - Y N Non sanitary waste discharged to the Title 5 system. ❑ es ❑ o Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 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: 1990 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints structurally sound, no signs of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 j Commonwealth of Massachusetts ,z Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for VoluntaryAssessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is Centerville MA 02632 11/02/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H2O Tank cover to grade. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Field Measurement/Mfg. Specs. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees in good condition, tank structurally sound, no evidence of leakage.Recommend tank be pumped regularly to extend life of components, inspection is not a guarantee of future system performance. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v � 611 Main Street Property Address Christopher Olson Owner Owner's Name information is Centerville MA 02632 11/02/20 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 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form (((Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4-' 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box level, no evidence of leakage, no evidence of solids carryover. Lt5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ile Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 611 Main Street v Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a nts Subsurface Sewage Disposal System Form Not for Voluntary Assessm e 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 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.): no evidence of hydraulic failure, no ponding, no damp soil. 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 UU" Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 611 Main Street `J Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. Cityrrown 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.): r t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cent.) 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 w , �,. ' r w t5insp.doc•rev.7/26=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 CommonlNealth of Massachusetts Title 5 Official Inspection Form 410 Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 611 Main Street V Property Address Christopher Olson Owner O•Nner's Name information is required for every Centerville MA 02632 11/02/20 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground.water elevation: Obtained from site observation, visual elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A � 611 Main Street Property Address Christopher Olson Owner Owner's Name information is required for every Centerville MA 02632 11/02/20 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 t For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 CN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments to�/�i�/,/✓ �"�". Property Address L'l�/Z/S Owner Owner's Name JJ information is 2/27//� required for • every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any , way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your cursor-do not use the return Name of Inspector key. Company Name Company Address /�lrI�YSFitty� ,�l�ss 40oy=- "� City/Town State Zip Code 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 211-7//z Inspector's Signature Date The system inspector shall.submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)`:within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Cfficat Inspection orm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ to/� J�•��M -5 Property Address Owner Owner's Name information is �f�/ry�y�LLf b2eo �-2711A required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ( I have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection-if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form- Not.for.Voluntary Assessments G// ,�IV $7- Property Address Owner Owner's Name information is �F.S�`TFi1�1/LLF. /P fOII• G�4 6 1 required for every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) N� B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address n Owner Owner's Name information is �� �,�f�f �I�j�. O 1G 31/ a/Z7►fi3 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ z Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ El IX than depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M SJ sy`. Property Address Owner Owner's Name information is ��/,/Tf2!/�LL f /yj�tfs. 02 G 3 y �,a7`47 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ [4 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ NQ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ 14A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ /IA Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ NA Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-, 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. L15ins Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is -7��� w/LLB /y5• D 2 L+1�/ ?�2 7//j required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Do 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? El ® 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) 5X f n/y © ❑ 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? IN El information 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. Ex ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 l\ f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Coif/!/S D�.CSGu� Owner Owner's Name information is required for 312711 every page. City/Town State Zip Code Date of Inspection D. System Information Description: AIA Number of current residents: Does residence have a garbage grinder? ❑ Yes Q No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes © No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes Le No Last date of occupancy: Date Commercial/Industrial Flow Conditions: N� Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pace 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) H1 Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: �D7A1y'*ez1'41 /(/4-;O?j Ayeo/cn-!:s Was system pumped as part of the inspection? ❑ Yes LB No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of.System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is /if-,41,-1 ��L� required for l� every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Not Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Hb yse Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Al owner Owners Name information is CI�,y�S���L a26 3y Z127// 3 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D�fTLFT>�/vf 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.): mn /S fv frX , 0,15 r ro 04el,4 0 r gr/110' C•�/1/L/O�P� •�d �UlOfit/Gj D�' L.f'.f•��f 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.): y� Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C'oVni3 , /�L�soel Owner Owner's Name information is �� f/LUf �Y.dtSt• !G 2WgI/ Z1Z7//3 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ley" Depth below grade: feet Material of construction: [� cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: [� concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: .S''�S'r f' /O oa e.'& Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is ��yrr�diu G1G ?7143 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness T'-Z Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): /�FCCv�sf.vr> 7i •vim ,c'IEoawrrpya -u���i� S7'AjVe -all L /•►?:Go c o, 1/�!//O iC fs�f L Al�U yo 6014000we'E yoIV, Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date, t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner Owner's Name information is 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;): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is ��•�?�� /L� � f•required for 026 3'Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: I ❑ 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.): i 14 t, i I I• so/4. 1 s 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 15ins•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /n Owner Owner's Name information is ���' a2 63.e/ �27/ required for y3 every page. CitylTown 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 r -o W t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address L'<fa/S Owner Owner's Name information is �P�/"l�/1l��Ll�' III• �j���c� Z�z7�/'S required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: © Check SlopeLT'v m Surface water ��� 0 Check cellar © Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts r Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form Not for Voluntary Assessments G1! ow Al-4/ ST Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E2 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 Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 -em and Your Septic Syst ■ �'W it It is important to understand how your system works and how this treatment affects it in order to protect your investment. The typical system consists of three (3) main components. The Septic Tank The Distribution Box The Drainfleld The Septic Tank Waste exits the house and enters the septic tank where solids settle to the bottom, grease and scum from the household detergents float to the top, and liquids stay in between. The solids that settle create.their own bacte- ria which decompose the solids naturally. There is no need to add additional enzymes and bacteria to the tank. The tank eventually fills with solids and scum requiring it to be pumped. A septic should be pumped every two (2) years. The Drainfleld The liquid (gray water) flows to the distribution box where it is evenly dispersed into the drainfield. Finally, the drainfield begins treating the gray water. Microorganisms in the soil consume organic pollutants in the gray water and the pure water is absorbed by the ground below. How Problems Start From the first day of use, the drainfield of your septic system begins to deteriorate. Some solids, grease, and scum always pass through the septic tank into the laterals. This is because of natural solu- bility or the lack of setting time in the septic tank during periods of heavy use. Problems especially, arise when the septic system is not maintained and the septic tank fills with solids and scum that ov ow into the drainfield. As the drainfield becomes clogged, the water flow becomes restricted. Since the water cannot drain into the soil, it filters upward causing ponding, foul odors, wet spots in the yard, and an unhealthy envi- What Causes Problems What you don't read about is that bacteria has a waste called biomat, and they also create a gas, bacteria eats human waste. It does not eat, hair,wool,polyester and other particles. The biomat is like grease. The gas cre- ates bubbles and this causes particles to float up the T and into the distribution box and into the leeching fa- cility,plugging up the stone. Septic tanks should be pumped every two (2) years. Cesspool Cesspools were made by digging a hole in the ground and walls were made of stone then later on they were built with concrete blocks. The waste entered the cesspool, and solids settled to the bottom, the liquids seeped out the sides into the soil. Cesspools should be pumped every year. State Environmental Code Title V Chap. 5 Inspection Procedures Guidance on Completing Inspection Form Part A Certification. The Certification Section has two principal functions.First it provides identification information on the property being inspected and the inspector. Second, it presents the results of the inspection relative to the failure criteria outlined in 310 CMR 15:3 01 In the certification statement, the inspector is certifying that the conditions existing at the time of inspection are accurately presented in the inspection report. The inspector is not certifying that the system is adequate for the current use of the system nor for the future use of the system. TONY CAPONIGRO 216 North Main Street Mansfield, MA 02048 Title V Inspections a No..7e-- Fmcl...30.00.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliraiion for BifiVaiial Workii Tomitrur#iun j[rrutit Application is hereby made for a Permit to Construct ( ) or Repair R an Individual Sewage Disposal System at: .611 Main Street Centerville Foster Location-Address or Lot No. O W J.P.Macomber Jr. wner Address Installer Address Type of Buildin Size Lot............................Sq. feet �., DwellingNo. of Bedrooms__._________2_____________________________Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures .-------•-----------•--•-•-•--------------------------.....-••---------------------•--.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth................ W 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch - Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_--_•_•----•-•-----____- a' ---••-•-----•-•-•---••-•---------•---••-----•-•-•--•---•---••--.....-•--•-•....-•---•---------------......................................................... ODescription of Soil------------------------------................................................-----------------------•-----......----........----------------------.................. x Sand & Gravel v ..............•----•••----•---••---•---•-----•-•-•••........-••----•----•-----••--•----•••--•--••---••••...-•----•---•-•--••-•••--------••----•-•----••-•----.............._......-----------•--••------ W UNature of Repairs or Alterations—Answer when applicable................................................................................•.......__..__. ------------------------------------••--•-------•----•--_1.-1Q J.....tan k;--•-1-1Q00•-•leach_-...t-.-••--•-•------•-•--•-•-•-••----•----•........._.......••. Agreement: 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 Compliance has bee sue�theboa.r of hea Signed Dare Application Approved By ............... ....... Application Disapproved for the following reasons- -- -----------------'--. ------...--------------------------------------......................................... ................ ' ---------- -------------------------------------------------------------------------------------------------------------' -- --------...---------.------------------------------------------------------------------ -----------------------------.-........ Dare PermitNo. --------�VF.Q.-------3. ----------------_-- Issued ..------------------------------------------------ -------------- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of C ampliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by P.�. 2.^ m A N�....Jr..' n.................I's ...... nstaller at ......6.7w1-Matn.... 1reet__fen erville " ' ' ' has been installed in accordance with the provisions of TITLE 5 gkThe State Environmental Code as described in the application for Disposal Works Construction Permit No. ....... _..... -------. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU �itANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. --- -- DATE...... Y��v.. Inspector .1.=------...---/'-V-- '".'=----�,,:----- .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C�f' TOWN OF BARNSTABLE No.....11 .-.:���.-3 FEE.., ... .�n .. Disposal Vorks Tonstrnrtion 'rrmit Permission is hereby granted..,!..R..M an.rlh.P n..:7r.,.....................................\........................................................ to Construct ) or Repair ( ) an Individual Sewage Disposal System at No.. 6 1 Main Street Centerville....- --------------------------------------------• ••-•-•--•-- Street as shown on the application for Disposal Works Construction Permit Dated.......................................... ..................................1 ..... -.th------ DATE.................... ��.-. _..�..----.... ...... Board of Heal FORM 36506 HOBBS&WARREN.INC.,PUBLISHERS t Fxs. fin,�n 47 THE COMMONWEALTH OF MASSACHUSETTS t ' BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Toostrur#ioo truti# Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: .............. --•-------=---------------------- ----- �Location-Address V or Lot No. .._F'ZS- P r -.......................• .....----•••--•-••-•----------------•---------. ..........•-...................................................................................... Owner Address k�.Qr...J.r.................................................. ------.............------...._........-•--••------•-••--•--.....----......._........----•------... Installer Address Type of Building Size Lot............................Sq. feet Dwelling ;No. of Bedrooms-------------a.............................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building --------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No: 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ FH ...---•----------------------•--------------......--._.•__.-----•__........-----.........._........................_....p.........._........_........••-••••- ODescription of Soil••-••-••-••-••-•••......---•---•-•••---•••---------------- ••--•*----...................................................... .........................- U �?.Ylf..Rv r �� l ........................................ ...............-----•............. r x •---•----------------------------•--•--•--------•-------------------••---•--------•--•-.....---------•-••-•-----•----•------•-•-------••----•-•----•-•----••--•---•--••••--•- U Nature of Repairs or Alterations—Answer when applicable...................................t,___.._._________...._______.................. ............ Agreement: 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 Compliance has beenAssued by the boar of heath. Signed . ........1-1.1 s............ .... .1..- 17) .0... Dare Application Approved By ..... � ------------------- -------- - ---- .. .........Jti ................................... ~Date Application Disapproved forth following reasons- ------------------------------------------------------------------------------------- ...................... ................ ------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------.................. 'Mte PermitNo. .......... --_-..�------------------ Issued ................................................. .......... Date . &L SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑A ent ■ Print your name and address on the reverse X ddressee so that we can return the card to you. . Received by(Print ame) C.ta e of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Y 1. Article Addressed to: If YES,enter delivery address below: ❑ No a W-A 3�t A W Sk C O"Z t , 3 l 3. Service Type M� o W Certified Mail ❑ Express Mail ❑ Registered Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number --- (transfer from service label) ; i ;i:710 5: 11611 0 0 191 2465 PS Form 3811,August 2001 Domestic Return Receipt 102595.02-M-1540 UNITED STATES, Qe}S' AL SERVICE _ ��y k g y y �mw Ft 'ass I�i}ei,��vw,ryylyy' CAPE CA:MA i..el4:..�Yl. O, B '@Pi ors.. trii L '� $z•Y. •r ,, r t wld�sr 6- • Sender: Please print your name, address, and ZIP+4"rr*4 box • :. Town of Barnstable Je Health Division 200 Main Street I Hyannis,MA 02601 . �j i�E!1!}titil�iili144ittlii?i!tll�tt}t�!!tt1�i7E1tE1�i44}!.lEtE4 Certified Mail#7005 1160 0000 0191 2465 SHE Tpt� Town of Barnstable Regulatory Services * UARNS'rAULE, + 9 MASS. m Thomas F. Geiler, Director �p 039. ArFb MAI a Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 15, 2007 Margo Altman 37 Walker Road Brewster, MA 02631 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 611 Main Street Centerville, was inspected on May 10, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the State Sanitary Code were observed: 105 CMR 410.190—Hot Water. Hot water off at time of inspection, however it must be between 110°-130°F. The following violations of the Town of Barnstable Code were observed: 170-10—Smoke Detectors and Carbon Monoxide Alarms. No CO detector provided on basement level. You are directed to correct the violations listed above within thirty (30) days of your receipt of this notice by installing CO detectors in accordance with Mass State Fire Codes and by ensuring the hot water temperature is between 1101-1301F. QAOrder letters\Housing violations\Rental ordinance\611 Main Street.doc ti You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER THE OARD OF HEALTH T McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector QAOrder letters\Housing violations\Rental ordinance\611 Main Street.doc TOWN OF BARNSTABLE LOCATION ��� , �I'J�.hr �? SEWAGE ? VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. j li SEPTIC TANK CAPACITY LEACHING FACILITY:(type) I (size)�,oao�L NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No NN'ZI' , 3y FORM 30 C&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BO OF HEALTH CITY/TOWN = W 1 V. b EPARTMENTLL f �V 'o RESS GSM 5 6�OW LEPHONE Address68 HOW (: A*Il/eOccupan Floor Apartmen >1o. No.of Occu ant No.of Habitable Rooms No.Sleeping Roomss No.dwelling or rooming unit No.Stories Name and address of owner �y QRemarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other.- STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: B Dampness: Stairs: Lighting: O STRUCTURE INT. Hall,Stairway: Kip T1e — Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters, Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room 79,P2 Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Q Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTIO EPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALT INSPECTOR TITLE ram/1 A. DATE ® IME A. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety r The following conditions, when found to exist in'residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to iricluae shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to 'include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. • . (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. f` �� Town of Barnstable �OFTHE � Regulatory Services BARNSCABLE, = Thomas F. Geiler,Director y MASS. �a 039. Public Health Division ArED MA1 A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 15, 2007 Attn: COMM Fire Health Inspector Meredith E. Morgan conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 611 Main Street Assessors Map-Parcel: (207-056): CO detector lacking in basement. Home is currently not occupied. Meredith E. Morgan HeaftK Inspector QAOrder letterMousing violations\Rental ordinance\\Fire ViolationsTIRE TEMPLATE.doc