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HomeMy WebLinkAbout0036 MEADOW FARM ROAD - Health (2) 36 Meadow Farms Road Centerville A = 189 118006 No. 4210 1/3 ®RA 10% `. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C�u 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name / information is Centerville V/ Ma. 02632 3-15-21 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 A. Inspector Information S � - �, -Lt filling out forms J on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. — V Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 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 OF 2. ❑ Conditionally Passes icy'; 3. ❑ Needs Further Evaluation by the Local Approving Authority 'o.. SEARS * No.SI14430 c 4. ❑ Fails AcFRrIF��<) : ,N StP,�``````` 3-15-21 Inspector's S' ature 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form ��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Rd. Main House u— Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts •I , Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts �n I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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 ears usage d 2019-450000gal g ( y g (gp )) 2020-501000gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 36 Meadow Farm Rd. Main House V Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system? ❑ Yes ❑ No 9 Y Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Cityrrown 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: 1-4-02 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 36 Meadow Farm Rd. Main House u- Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 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: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: .1" Distance from top of sludge to bottom of outlet tee or baffle 29" 0 Scum thickness 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? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal tank with in and out tees in place, inlet cover 18" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form <I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `............. . !% 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f c , Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 36 Meadow Farm Rd. Main House u— Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every 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.): D Box is 16x16 with 1 outlet pipe cover at 13" below grade I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. CitylTown 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: ® leaching chambers number: 4 ❑ 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 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. CityrFown 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.): SAS is 4- 500 gal drywells in trench pattern wells are clean and dry with no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .; 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required 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 A 6CIc4 a r0 0 X z OF t 3 MICHAEL�c�N o: SEARS =" No.SI14430 I.�, q it %'r� $RTIF� �o � 4 3- i� gi- rS 3- a.b O ® poo f Nous e t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 36 Meadow Farm Rd. Main House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every 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: 136"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: 7-11-2000 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: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form nts ! subsurface sewage Disposal System Form Not for Voluntary ASS2SSme 36 Meadow Farm Rd. Main House Property Address John Hunt -- --- Owner Owner's Name information is Centerville _ _Ma. 02632 3-15-21 _ required for every — -- State Zip Code Date of Inspection page. city/town 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 I ® 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 Gr,A Sr sAg r Y 0 6tw4w4 t r, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 t5insp.doc•rev.712 612 01 8 Commonwealth of Massachusetts 1 09- 1 I S-oo(p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5 I IS on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification inspector in full compliance I certify that. I am a DEP approved system with Section 15.340 of Title 5 p (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 H OF'MgS 2. ❑ Conditionally Passes MICHAEL '.N SEARS 3. ❑ Needs Further Evaluation by the Local Approving Authority k: No.SI14430 . 4. ❑ Fails T1��`� ��'��i,���s•1 N S P�C����`�� dnnnmu 3-15-21 Inspector's Signat 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. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u!% 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityrrown 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: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every 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): a year due to broken or obstructedpipe(s). The ❑ The system required pumping more than 4 times 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 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form lI p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r c � 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f c Commonwealth of Massachusetts �- Title 5 Official Inspection Form �Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... !% 36 Meadow Farm Rd. Pool House V� Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityrrown 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts �= Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... 36 Meadow Farm Rd. Pool House V� Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all s components, excluding the SAS, located on site? system ® ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form <II? Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House V Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2019-450000ga12020-501000gal Detail: Same meter as main house I 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 Commonwealth of Massachusetts Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for 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 r Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House u Property Address John Hunt Owner Owner's Name information is ' required for every Centerville Ma. 02632 3-15-21 page. City(rown 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: 1-4-02 Were sewage odors detected when arriving at the site? ❑ Yes ® 'No 5. Building Sewer(locate on site plan): 34" 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..............w 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 24" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal Plastic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: V. Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gal plastic tank with in and out tees in place, inlet cover 24" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `............. !% 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 1 outlet pipe cover at 28" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts p Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 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: ® leaching chambers number: 2 ❑ 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 L cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityrrown 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.): SAS is 2- 500 gal drywells in trench pattern, wells are clean and dry with no sign of failure 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c , Commonwealth of Massachusetts �n Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form - k 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name Ma 02632 3-15-21 information is required for every _Centerville State Zip Code Date of Inspection page. City/Town 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 Qack O 4-1 MICHAEL '.N o. SEARS *: No.SI14430 �''�,�T''•FRTIF� •;�0���• �51 d 3 -30.9 3-39 3 � Q A O paa i i Title 5 Official Inspection Form:Subsurface sewage Disposal System•page 16 of 16 t5insp.doc•rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ 36 Meadow Farm Rd. Pool House u- Property Address John Hunt Owner Owner's Name information is Centerville Ma. 02632 3-15-21 required for every page. Cityrrown 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: 136" 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 000 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: No ground water per plan 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 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Rd. Pool House Property Address John Hunt Owner Owner's Name information is required for every Centerville Ma. 02632 3-15-21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 6 rode 1.S� .� --T 6,4+ew, of SASrr �I d� /✓17 �je`oJ ry�+ey�' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts ,,�^ `A . Title 5--Official Inspection Form t- ►S o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important:When filling out A. General Information / forms on the computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 few Cityrrown State Zip Code 508-385-7608 S13742 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 i -- inspection was performed based on my training and experience in the proper function and:malr tenanc6"Of orKs►te sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15 340 c Title 5 (310 CMR 15.000).The system: C:yyp ® Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 4`C9 / / 01� M 4�.�/ 05/01/10 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. 2� Commonwealth of Massachusetts Title 5 Official Inspection Form a s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ahvays 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. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than Y2 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M s•''� 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is Centerville MA 02632 05/01/10 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate ayes"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? ® El Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field(f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Unbazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Citylrown state Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 for example: 110 x#of bedrooms): 440 ( P gpd ) Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cfty/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known) and source of information: 01/04/02 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °'~ 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is Centerville MA 02632 05/01/10 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.6 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.): i Septic Tank(locate on site plan): Depth below grade: 0.8 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" . Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every 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.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ' Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) 0ocate on site plan): Depth below grade: Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in wonting order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required forCenterville MA 02632 05/01/10 every page. cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overFlow cesspool number: ❑ innovative/aftemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has four 500 gallon drywells in a 13'x 42'field of stones.The dryweils were dry with no sign of ponding or failure. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Meadow Farm Road Property Address. George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. cityrrown State Zip Code Date of Inspection D. System Information (cunt:) Sketch Of Sewage Disposal System.Provide a sketch of the sewage disposal system including'ties to at least two permanent reference,landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i Y 6� 74 1 TOO, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS). ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required forCenterville MA 02632 05/01/10 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. Impotent: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key p to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address ( }� East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 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 rt5air)tenance of on + sewage disposal systems. I am a DEP approved system inspector pursuant tow'Section 15140 OEE Title 5(310 CMR 15.000).The system: �= -' ® Passes ❑ Conditionally Passes ❑ Fails; w ❑ Needs Further Evaluation by the Local Approving Authority + T- � c 05/01l10 Inspecto 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. VV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '( 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is Centerville MA 02632 05/01/10 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in'the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6'below invert or available volume is less than Y2 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. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy Is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or`nos 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 11 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate ayes'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? 0 ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms(actual): 0 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is sequined for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 04/09/04per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Udbazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 1.9 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: 1.3 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 -----------7--------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gal Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityfrown State zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 9 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): I h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityr town State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has two 500 gallon drywells in a 13'x 22'field of stones. The drywells were dry with no sign of ponding or failure. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required for Centerville MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information Centerville required for MA 02632 05/01/10 every page. City/Town state Zip Code Date of Inspection D. System information (cont.) Sketch Of Sewage Disposal System: provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1'�tlln is I TOO • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'GSM 36 Meadow Farm Road Property Address George Uribazo Owner Owner's Name information is required, for Centerville. MA 02632 05/01/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation.. ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet Net����® Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Pe, ► PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for �Digponl *p5tem Construction Permit Application for a Permit to Construct Repair Upgrade bandon �Complete System ❑Individual Components �] Locutioand n dss aorr L1 N Owner'sName,Address Tel.No. 3 ' ®W Asesor sap s, o Installe s Name,Ad res land r jC �-� l Designer's Name Address and�Tell. No. � 0 y�1� 0U 2 Type of Building: Dwelling No.of Bedrooms Lot Size ' -sq.ft. Garbage Grinder( ) v c Other Type of Building No.of Persons Showers( ) Cafeteria( ) nfi Other Fixtures o��VVV Design Flow gallons per day. Cal lated daily flow gallons. Plan Date 60 0 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 Certifi- cate of Compliance has been d ky tWj fpjrq qf th. c Signed VI )"U \z,�_Date Application Approved Date Application Disapproved for the following reasons Permit No..?,!:�'y Date Issued 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application forigoaY �p�tem �o,nfructton hermit nApplication'or a Permit to Construct Q� )Repair( )Up lade( ) bandon( ) ]Complete System individual Components ' Location ddress otiLot No. Owner's Name,Address and Tel.No. N S�v1►(�1R COtJj D� � Asse sor s ap/P 1 20 Y�C, 5 UI5 (a(oD ! cz�, Installe s Name,A ress�azid ' Designer's Name,Address and Tel.No. r I L c�J C- L C Type of Building: ,f - , Dowelling No.of Bedrooms Lot Size43iP sq. ft. Garbage Grinder( ) L Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures _---�` Design Flow gallons per day. CaI lated daily flow gallons. Plan Date Number of sheets J— Revision Date Title Size of Septic Tank Type of S.A.S. ­45 Description of Soil } Nature of Repairs or Alterations(Answer when applicable) - r Date last inspected: ' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with"the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been d y t ' oar lth. c�� �� 1 Date -,Signed Application Approved Y_ Date r .� " d s f Application Disapproved for the following reasons t Permit No.,?G-w /i.674 Date Issued = r ——————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS QCertificate of (Compliance THIS IS TO tha the On-site(�eDisposal System Constructed(� )Repaired( )Upgraded( ) Abandoned( )by at been constructed in accordance with the pr isions of Title 5 th for.3tis al Systeem Construction Permit '3401- rJ � dated Installer (A)m i1 tl I NY- Designer A—sr� The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ()) �n�� lklz- Inspectors .� ��. r t r -----------------r• ----- --ram-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 30iopogaf6potem (Construction permit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.Date: G 1 l C`I l�� �- Approved by � 1,v ) r •r W 1 TOWN OF BARNSTABLE LOCATION�fo m E'Apew F;,Tem pzp. CST 4 L 1 SEWAGE #Z00 1-`5 /,e VILLAGE ef-&)T�QUIL-4-E ASSESSOR'S MAP &LOT/8 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY If 6N=i 619 L LEACHING FACILITY: (type) ENCtl 4 Z `)C 13 'X Z NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: '7—2 'aI COMPLIANCE DATE: CTAN 4, 2z;002, Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility I-)1A Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) f} Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �44 Feet Furnished by k c—roryi2c' i 3 f001-3D. - 1 g 3 SZ ' (?' I � Z - 42 4 RIse,2. 3;Ser-. Town of Barnstable P# qno Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 nAmirrABr e, nrnss. ,p rE039. i Date Scheduled A)1, �� , _000 Time Fee Pd. DO Soil Suitability Assessment for Sewage Disposal Performed By: D A IJ IE L A. OJ A LA PLS , SG Witnessed By:IN NNA �4ioZ 4 4-Dl LOCATION & GENERAL INFORMATION Lpcat+nAddress VULLE2 �C-MS 43` v.4t (� Owner's Name FULLs2 Flia" CEWTEt2\ %LE I QPrQN51 A6LE� MA Address KC—AL_Ty TieuST r Assessor'sMap/Parcel: PbR-p N aF 1"/11$I0 ()6 Engineer's Name DOLVO6 pE EhJ&WECFP_irJ(� NEW CONSTRUCTION REPAIR Telephone# �50F) 3W_-J4S,+J Land Use (ACAtJT Slopes(%) 0-5 Surface Stones '- Distances from: Open Water Body — ft Possible Wet Area — ft Drinking Water Well — ft Drainage Way — ft Property Line SKETCH ft Other — ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) T w s r ( 50-a3' y T w F— �;O( —� 7" ( ,05Ac• ctiw�hT 35 ► Ln InL.99' T Parent material(geologic) GLACIAL OVTWASIJ Depth to Bedrock >ZOc7T Depth to Groundwater: Standing Water in Hole: N/A Weeping from Pit Face Estimated Seasonal High Groundwater N/A No Ge_oQwt)LJATE2 Pt3 i) . TERIVDNA TIQI i l�"OR.SEAS N - MGM WAT'EI 'Y'AI T I; Method Used: Depth Observed standing in obs.hole: N/A in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment N A ft. Index Well#___.__..-. .Reading Date: Index Well level. Adj.factor Adj.Groundwater Level\TVA PER. T QN VEST Iaate 4 I►me + . .. ..... Observation T Hole# l f�_ Tip 2 Time at 9" Depth of Perc l0 I� a u P Time at 6" Start Pre-soak Time @ 0:00 0 Oo Time(9"-6") End Pre-soak `J-.40 6 V P4 �4 Rate Min./Inch Lot L cZ V) �" 0 In V40 Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(Y/N) I'll Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBSERVATION HOLE LOG. Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel D ; •-., l 0� nit 10 J2 qg- 12 A hoam � I'D -3o Q amrn� a•S y2 ��/1� 3o-13? &,,J 26 12 �I3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel O-z o ©►' u" Ib �� Sly 2-W 64 Loa'rnj 3,r,d to lk 6/2- -'a� Q Loam Sam Is 12 -7l(., �$-l3Fs C, y�Z -7/3 .. DEEP: OBSERVATIOlY MOLE LO;( Bole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel j" DEEP OBSE�2V ATON`HO.tiE LOG HoXc -. P . De th from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistent %Gravel I Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring_Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? yES If not,what is the depth of naturally occurring pervious material? — Certification I certify that on N a V 9 S (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature \ ��j 1 Date �If oo 0 P A1#03 1 TOWN OF BARNSTABLE LOCATION Z MEAP4X0 E-42M IZn, 6-0 4> SEWAGE VILLAGE C E-K)7�,1214- E ASSESSOR'S MAP &LOT '8 —144 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I SGo G� L LEACHING FACILITY: (type) ENcf] Z l.3 X; �C NO. OF BEDROOMS )ize) 42 ` BUILDER OR OWNER v` C-04 t N,4kA Cv NS'TR-G�TOA) PERMITDATE: r7`Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) LA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Feet Furnished by M. • k`�c9TYr2� 2� �D N r . A - 3 = +�Z- Xi s 11 3 - = l 4' 0 3 = SZ ' e q = ('1 ' r " : 4 �, Rises 2isE� 4 ` TOWN OF BARNSTABLE L6CATION 36 MEAPOLU F/Ieb P-R, �Lo; 4) SEWAGE# 2061 - 5718 VILLAGE d E tjTr_,2V t t-CE ASSESSOR'S MAP&LOT!8 1 ib INSTALLER'S NAME&PHONE NO. C `SNTYR.£ 3 631:;--9 4 0! SEPTIC TANK CAPACITY 1 S0 0 GAL, LEACHING FACILITY: (type) (size) I ° K Lt 2- NO.OF BEDROOMS 4 BUILDER OR OWNER 6F.�r ►JA-2A PERMIT DATE: 7" Z—O I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) NZO, Feet Furnished by F— r 9OA-P FavND. O, - � = � � � RisE Z_�Z� 3 RISER 4 F 2a-0" A 6-19/4° M101/4" ATTIC ACLE55 (p © 9 - - — — — — — — — — — ,. — - - — — — — r g�g N — — ` — — — — — — — — — — — — — — — — — — �p AnIQ PLGE55 24'-0' 16-0" 5-01 4'-6' 6-6 oa � Q 2 29se JTE I I CAM 60 rrsF%fi`t a I i II IIv II I ll A ll x ll I I II II�N II I all I II II II I I II II II� I r rr Ir rr Q q r �� _Ln Y I Q ( _ 2668 2466 - C 2010 4'-0' 9-0° 9-0" 9-0" 16'-0" PMWM Py =JAYM. CAS AZO RESIDENCE c 506) 598 www,cadde5lgny,6lz P�516 MBA W wM F0AV - CeMTUVIl. , MA, -� ARA CONSTRUCTION CORP. v F I WU 55MIMMA (508) !785-2605 TEST HOLE LOG DATE: _✓ULY ��L ZDl70 /o ct� SOIL EVALUATOR: WITNESS:--.Z-71, ` PERC RATE: . c Z ZV 0y'e L \ \ c.S • A e, S, �y /o yrc s Z g" tcye S Z Q G. S, 19 L S. 0� i v �' Z,5y*X ,Sza Z.5A-7/v 64AJ p /_334 3 ` z.s 3Z.s Zo7- `�' y3Giz 'sF', /yo ws,�TErr ��c/cod,lTG,eGa ' r\ CO DESIGN DATA DAILY FLOW: (�/)'PDRMS.z 110 GPD=S�YG GPD �%SEPTIC TANK: dGPD I<200%=88 o GPD USE:/J;_c-o GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE:(,-/)3 '5z �XS.SX Z.^- Soo Q.Q�/t�JFcc3,9, �s2y 'a� a0m. 3y , 6;. v" CAPACITY: c� SIDEWALL: l-%P.r e is o.> =Age,g BOTTOM: IS 51Z,<o.),/l Val,o. TOTAL: S� 8 �ia• OF DANIEL E. CSG T BRAMAN U RR p o RUM ti o CIVIL 7 � ci �32 6C O y 9�FESS�O�P�Q, NOTES: qNA Sl RV� c 2 - t7� FSSIONALE�6 1. ALL PIPE TO BE 4"DIA.SCiI 40 PVC. - 2. PIPE TO BE LAID LEVEL FOR V OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. -� 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE 6. INSTALL GAS BAFFLE IN OUTLET TEE. 31 LATER OF4•-1 1/2"WASHHEDD STONE OVER y17 ONE ALL AROUND ; 3 TOP OF FOUND. y�jv @ EL 5'o.do / ys�s ys zs Ys ov S� • SEPTIC SYSTEM PROFILE SITE ^r SENVAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION / OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR ......... TO ANY EXCAVATION OR CONSTRUCTION. � Y° 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH ' PREPARED FOR 3I0 CMIR IS.00:TITLE Y. I ��iy/riW�2/4 CO�S��(,,>G T/0��. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. — - 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. 'g B� 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY DATE: ::Z-L '------ SCALE: 095 E.<a -- REQUIRED INSPECTIONS. k it 1 AA 'x WELLER & ASSOCIATES FT[ 1645FALMOUTH ROAD CENTERVILLE, MA. 02632 EL: (508)775-0735 FAX: (5081775-0754 APPROVED BY: .�y O YZ � N 000 1 � All PP--,Off I LE NOT 1-0 66ALE TEST HOLE LOGS py ROUTE � � cp 2"'LAYER OF-5/5"PEASTONE FIRST PIPE LENGTH OVER 3/4"— I I/V'DOUI31_.E DATE:X LY 112000 P-5503 CRIHIN TO �E SET LEVEL WASHED STONE TEST PY: P.OJALA,615E P Fug RIP. TOP FOUNDATION OVES TO WITHIN W FNESS: D.Mi':RANDI DARN.HEALTH DEPT. �¢ EL= 30.5 /v'" GE FINISHED GRADL. fop, 2" PERO RATE: <2 MIN./IN_ FARM , cp FINISH GRADE LANE �- EL.= 30.0f A3.0 d 440 d' G1J5 C Uz6ANIG PV 1„ = SC,i 1 V0 •, Ap = LOAMY SAW Ap = LOAMY 6AW z _ PVC, 4„ PVC TO' @ EL. 7-7-3 (EXIST.) 25YR5/s 2.5YR5/2 $„ w SCH 4D °e° �25 27.75 27.0 Z (EXIST.) ° ' ° '° ° f5 T 6)M @ EL 25.10 (EXIST.) _ 7 SAW LOAMY sANv _ INSTALL 6AS fwF LE / AL7 2 5YR7 6 �„ 28.00 IN OIrLET TEE 27.�0 DIST. f7OX A05 1d' LOCATION MAP 1500 GALLON NOTE: SEPTIC, TANK EXCAVATE ANY IMPERVIOUS MATERIAL FOR A 5 RADIUS AROM THE 6 _ MlEpw SAW EAW 6"" STGN%'. SASE LEACHING FACILITY AND REPLACE WITH OLEAN MEDIUM SAND. 2.5YR7/3 25YrZ7/g NO WATER ENCOUNTERED - DEs I CAN DATA DAILY FLOW: (5)13EDROOM6 x 112 GPD=550 C-PP SEPT K.TALK:550 OPP x200%=190 GPD USE:15200 GALLON PRECAST SEPT L' TANK LEACHING FACILITY: USE: (4) 5' x 5.5 500 GAL PRECAST DRYWH.LS LINED W/4' OF DOUBLE WASHED STONE CAPACITY: L�- 51DEWALL: IZ3 x 2 x 0.74 = I820 C-PP Y i5OTTOvf: 599 S.F. x 0.14 _ 4-A3.3 C;PD A-451 ' LOT A - T=Z2.87 3z OENERAL NOTES I CONTRACTOR TO I3E RE5PONSIt3LE FOR THE LOCAT►2NOF ALL UTILITIES, ABOVE AND UNCERC�ROUND,PRM TO ANY EX6AVATJ9N OR CONSTRUCTION. 2. SEPTL SYSTEM TO f5E INSTALLED IN COMPLIANCE WITH 310 CMR 1500:TITLE V �_ _-----�—.. 3. THE PLAN 153 NOT TO ICE USED FOR PROPERTY LINE DETERMINATUN / A. ALL Dr::,TUR f5ED AREAS TO PE LOAMED AND SEEDED 5. CONTRACTOR TO PROVIDE U HOUR NOTr,E FOR ANY REQUIRED INSPECTNS - Ex�riNtrtl50o6 AL IZ=140.0a _ WILDLIFE I CONSERVANCY �x�ri LEAGti1 ' EA EASEMENT NFL N6 a (TOREMAIN)f AR EA N / T ( -TL �EWAOE PLAN �¢ x .� 32— 8 7r / LOCATION: 36 MEADOW FARM RD., CENTTERVIH E, MA Sc, PREPARED FOR: OEORGE & OINA URIf5AZ0 0 SCALE: DRAWN 13Y: �� TMW ZN OF MqJ *�OFi f � DATLf � NWff- APRIL 7, W04 SHEET: EN DANIELE. REV.: SP—IiJ1 CIVIL REV.:35 9 #1I N 3 686C �' I s�k q x sSTS WELLER & A 061ATD5 1645 FALMOfft1 RP - SUITE 46 CENTERVILLE, MA OU'�12 ` - S J TEL.: (508) TI5-0735 N FAX: (505) 775-6 754 PROFESSIONAL ENGINEERS & LAND SURVEYORS i