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HomeMy WebLinkAbout0051 MEADOW FARM ROAD - Health (2) �1 Mea+dow Farms Road Centerville A = 189 118003 F ,�llll �/// ® y UPC ed 12534 tdo.22 3LL R HASTINGS,MN k r 1 Commonwealth of Massachusetts e Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Rd. ' Property Address r , Baebara & Kevin Radous , Owner Owner's Name information is / required for every Centerville b Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 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 r� 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 I t10 F'117q 2. ❑ Conditionally Passes zJ' MICHAEL 3. ❑ Needs Further Evaluation by the Local Approving Authority 10:' SEARS No.SI14430 4. ❑ Fails "'I'44 ui i N S atG```" 9-11-20 Inspector's Sigperure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I- i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Rd. u Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 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: ® 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: 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 c Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N 0 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam, Commonwealth of Massachusetts �n :. Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 51 Meadow Farm Rd. V� Property Address Baebara & Kevin Radous Owner Owner's Name information is Centerville Ma. 02632 9-11-20 required for every 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 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 i c Commonwealth of Massachusetts Title 5 Official Inspection Form .yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Meadow Farm Rd. u- Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 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/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is,within 100 feet of a surface water supply or tributary to a surface water supply. El ® 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 cam, Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Rd. V Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 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 cam, Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 51 Meadow Farm Rd. u Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2018-161000 gal g ( y g (gp )) 2019-182000gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes; volume pumped: gallons How was quantity pumped determined? Reason for pumping: L doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form /I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u � 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2001 #2001-591 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 3' 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 i Commonwealth of Massachusetts �v e Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 26" 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 Sludge depth: 1" Distance from top of sludge to.bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Sludge judge, tape, plan 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 in and out tees inlet cover 4" below grade outlet cover under brick walk t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 4 Commonwealth of Massachusetts �n Title 5 Official Inspection Form <lI; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vic !% 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is Centerville Ma. 02632 9-11-20 required for every page. CityfFown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts �v p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �C 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is ill t enerve Ma. 02632 9-11-20 s required for every C � 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 with2 outlet pipes cover at 2' below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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 c � Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments + � 51 Meadow Farm Rd. Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 3- 500 gal dry wells 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 �v Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Rd. u� Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 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 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Meadow Farm Rd. u Property Address Baebara& Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 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 tc Rox 4T i� xis u r r .2 0 Eli?3 0 3 \����aumipuiz lis MICHAEL9�yN o SEARS ; *t. No.SI14430 y ',����j•.FRTIF�� _ sf INIStPG`````�� _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 cam, Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 51 Meadow Farm Rd. u— Property Address Baebara & Kevin Radous Owner Owner's Name information is Centerville Ma. 02632 9-11-20 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 1501, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Rd. u� Property Address Baebara & Kevin Radous Owner Owner's Name information is required for every Centerville Ma. 02632 9-11-20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist).completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ■ A Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface_Sewage Disposal System Form-Not for Voluntary Assessments 51 Meadow.Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name information is required for every Centerville MA 02632 1 A I A4 page. Cityrrown 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 and of the form_ Important:When A. General Information filling out forms `tttttuUHrUr�r��� On the computer, xOFlygs�ii���� use only the tab 1. Inspector: key to move your cursor-do not James — JAMES 'm key..the return Name ofSeafS 'U: Inspector co Z CapewideEnterprises,LLC �T � ¢ � Company Name � I• . �TI-F ,� �� 153 Commercial Street ''� �S�i Ns �G```���� . � Company Address Mashpee Ma 02649 CityfTown State Zlp Code 6008-477-8877 S1623 Telephone Number License Number 8. 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 arid experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000�.The system: ® Passes ❑ Conditionally Passes ❑ Fails r ❑ Needs Further Evaluation by the Local Approving Authority 1-13-14 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board w of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flour 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 condihons a-t 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. I t5ins•T13 Title 5Offiael Inspect) tiw sAe Sewage Disposal Sewa Disposal Syslem•Page I'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name required on is Centerville MA 02632 1-11-14 required for every page. City/Town state Zip Code. Date of Inspedion B. Certification (cont.) Inspection Summary: Check.A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described ' in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over.20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass • inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.3113 Tale 5 Official Inspedion Fomti Subsurface Sewage Disposal Sysfem•Page 2 of 17 r•- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name requiratifore Centerville MA 02632 1-11-14 required for every page. City/Town state Zip code Date of Inspection • B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally.Passes (cont.): ❑ Observation of.sewage backup or break out or high static water Level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or luneven 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 0 -Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which reqL ire further evaluation by the Board of Health in order to determine if the system is failing to prot ct 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 systi im is not functioning in a manner which will protect public.health, safety and the environment: ❑ Cesspool or privy i within 50 feet of a surface water ❑ Cesspool or privy i within 50 feet of a bordering vegetated wetland or a salt marsh *ns-3I13 THIe 5 OfBrSal Inspection Form Subsurface Sewage Disposal System•Pape 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments... 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name information is required for every Centerville MA 02632 1-11-14 .page. Gtylrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any). determines that.the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water.supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply_ ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and-the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria.Applicable to All Systems: You must indicate"Yes" or,"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or r 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 n 1 m E.is less than 6' below invert or available volume is less than 1/2 day flow l£,9 t5ins-3A 3 Tide 5 Olfidal InspeWan Farm:Subsudaoe Sewage Disposal System•Pago 4 of 17 Commonwealth of Massachusetts C Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .ip 51 Meadow Farm Road Property Address Kathleen hl_Smith 2003 Revocable Trust Owner Owners Name information Is e required for every Centerville MA 02632 1-11-14 page. Cityfrown State Zip Code Date or inspection B. Certification (coat.) Yes No Required pumping more than 4 times in the last year NOT due to clogged br C. obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ® tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 1.00 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 certifled 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 falls.l 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.Systerns: 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-1WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered.a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department:. 15ins•3113 Title 5 Offidal InsDoe ion Form:Subsurface Sewage Disposal System.Page 5 of 17 J C711 I J I Y I I.JVGI - r'- R Commonwealth of Massachusetts 1 19 Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2603 Revocable Trust Owner Ownees Narne information is Centerville MA 02632 1-11-14 required for every page. CityfTown state Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no"as'to each of the following: Yes No. ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 none as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ Were all system componen is,'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 ® El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System ISAS)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 El approximation of distance is unacceptable) [310 CMR 15.302(5)] ` D. System Wdrrhation . Residential Flow`conditions: Number•of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official inspection Farm:fiubauftw Sewage Disposal System•Page 6 of 17 JGI'1 IV IT 1 I.VJG ' r' Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments. M 51'Meadow Faun Road Property Address Kathleen M.Smith.2003 Revocable Trust Owner. Owner's Name information Is MA 02632 1-11-14 " required for every. Centerville page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank D Box and three 500 Gal.dry well's. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry.on.a separate sewage system? (include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes Q No Water meter readings, if available last 2 ears usage d 2012-387,000GaI g � y 9 (9P �)� 2013-154,000GaI's Detail: Sump pump? Q Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: Design.flow(based on 310 CMR 15.203): Canons per day(gpd) Basis of.design flow(seatslpersons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial_waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Of kiol Inspeabn Form:Subsurface Sewepe Dispoeal SysWn-Pape 7 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.'Smith 2003 Revocable Trust Owner Owner's Name information is Centerville MA 02632 1-11-14 required for every cti State Zip Code Date of Inspeon page. Cityrrown D. System .16formation (cont.) Last date of cccupancyluse: Date Other(describe.below): General Information Pumping Records: Source Of information: NA. Was system pumped as part of the inspection? ❑ Yes 0 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 El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): F t5ins 3113 Title 5 Official Inspect n Form:Subsurface Sewage Disposal Syslam•Page a of 17 -Jai 1 10 1`t 1'I'.JJa - N•� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name . information is, Centerville MA 02632 1-11-14 required for every page. Cityrrown State Zip.Code Date of inspection D. System Information (cont.) . f Approximate age of all components, date installed(if known)and source of information: 2001 Permit# '2001-591 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building:Sewer(locate on site plan): T 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.): Pipeing is 4" PVC SCH ~ 40 Septt nk(locate on site plan): 26' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) - if tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast 1I Sludge depth: t5ns-M3 Thle 5 Officiel Inspedion Form:SubeuftW Sewage Disposal System-Page 9 of 17 Jan ,10 114. I I,•.4Va N• V Commonwealth of Massachusetts - Title 5` Of tr►spection Form Sewage Se Disp osal System Form Not for Voluntary Assessmen ts � . Subsurface g P Y 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name information is Centerville MA 02632 1-11-14 required for every page, Cityfrown State Zip Code Date of Inspection D. System Information .(corn.) Septic.Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" 0" Scum thickness 8" Distance from lop of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level:Tank at 26" below grade w'inlet cove at 4". Outlet cover under brick walkway fn and outlet tee's No sign of leakage or overloading. 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 4 Date of last pumping: Date !Sins-3l13 '1109 5 Official Inspection Form:Subsurface Sex4E9e Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title ,.5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Meadow.Farm Road Property Address Kathleen M_Smith 2003 Revocable Trust Owner Owner's Name informat►on is Centerville MA 02632 1-11-14 required for every page. Citylrown. State Zip Code Date of Inspection D. System Information (cunt.) Comments.(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: (]concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: bate Comments(condition of alarm and float switches, etc.): - "Attach copy of current pumping contract(required). Is copy.attached? ❑ Yes ❑ No t5ins•3113 Title 5 Orfidal i specllon Form:SuDaurece Sewage Disposet System-Page 11 or 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not For Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith`2003 Revocable Trust owner Owner's Name information is Centerville MA 02632 1-11-14 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-2'below grade. Box is clean and solid w/two line's out No sign of over loading or solid carryover -- Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorptibn System(SAS) (locate.on site plan, excavation not required): If SAS not located, explain why: l5in&•3�13 Tide 5 Official Iropeemn Forst Subsurface Sewage Disposal System-Pape 12 of 17 'Jd1P IJI�h 'I I:�FIG N• v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen MiSmith 2003 Revocable Trust Chvne.r. . Owner's Narne. information is MA 02632 1-11-14 required for eve page Cityffown State ' every' Centerville Zip Code Date of Inspection D. System (information (cont.) Type: ❑ leaching.pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ in novativelalternative system Type/name of technology: r- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is three 500 Gal.Dry Well Chambers wl4'stone. Chambees are 2' below • grade.Chambees'are clean and wet.WaINS clean like new. No sign of over loading or solid carry over. • Cesspools (cesspool must be pumped as part of inspection)'(locate on site plan): Number and'.configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3113 Title 5 Official Inspection Form:Subestace Sewage Disposal System•Pape 13 of 17 .;an to i4 i i,:,+ia Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Meadow.Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owner's Name .information is Centerville. MA 02632 1=11-14 required for every State. Zip Code Date of Inspection page. Cityfrown D. System Information (cost.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins-3113 Title 5 Official frzpoction Fomr.Subsurface SewsW Dispossi System,Page 14 of 17 jan io.i,+ i,l,;4ia N. Commonwealth of Massachusetts. . Title 5 Official Inspection Form k subsurface Sewage Disposal System Form-Not for Voluntary Assessments r. 51 Meadow Farm Road Property Address Kathleen M.Smith 2003.Revocable Trust Ownef Owners Name information is Centerville MA 02632 1-11-14 -, page. CityfTown red Eor every state Zip Code Date of Inspection . .page. D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or.benchmarks. Locate all wells within 1.00 feet.Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ,u IL B--� 3�� 3 � G O 0 3 • t5ins•3113 Tile 5 Official kiweclion Form:Subsurrace Sewage 0•isposal System•Page 15 of 17 Jd11 IJ IY 1 I,'YGGI i.J. ly Commonwealth of Massachusetks Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner owner's Name information-is Centerville MA 02632: 1-11-14. required for every page City/Town State Zip Code Date of Inspection D. System Information (cont) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar Shallow wells N�, Estimated depth togh ground water. feet 12'-6" 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: T.H.on Designn plan 7-11-2000, No G.W. at 12'-6". Bottom of chambers at 5'below grade. Bottom of chambers at T-6"above T.H_depth. Beforefiing this Inspection Report,please see Report Completeness Checklist on next page. I5ins 3/13 Title 5 Oflldal Inspedlon Foam:subaufaoe Sewage b1sposel System•Page 16 of 17 li Commonwealth of Massachusetts ff Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 51 Meadow Farm Road Property Address Kathleen M.Smith 2003 Revocable Trust Owner Owners Name information a Centerville MA 02632 1-11-14 required for every page. City/Town State Zip Code Date of Inspection `. E. Report Completeness Checklist ® Inspection Summary:A, B. C, D,or.E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tSins-3113 TWO 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 17 of 17 R Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms the computer, r,use 1. Inspector: only the tab key to move your Robert paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this add;;ess and th5t'the -n information reported below is true, accurate and complete as of the time of the inspection. T,he ins ction was performed based on my training and experience in the proper function and maintenance of ori.5,s''te sewage disposal systems. l am a DEP approved system inspector pursuant to"Section f5.340 Title 5 (310 CMR 15.000).The system: �n rrn ® Passes ❑ Conditionally Passes ❑ Fail ❑ Needs Further Evaluation by the Local Approving Authority 11/03/2010 Insp tor's ig ure 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. [A6- t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No . Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage NA 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11/03/2010 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology..Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 51 Meadow farm Rd. M Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System Vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 2° t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. Systems Information (cont.) Septic Tank(cont.) 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 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.no evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments note condition of um chamber, condition of pumps and appurtenances, etc.): ( pump P P PP ) Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): sandy dry soil.No signs of hydraulic failure.Water level was 18" below invert at time of inspection.No stain line observed higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Trap Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® Zoom Out �In y he R.a �) 7�R. I[L i � 7 � �'?pt.•i�',Ar �rLllt.. ��'s�N1A�t'd'� y'� �s3 a t - r i 4%• 1 O .......................i 0 20 Feet Set Scale 1" 20 I Aerial Photos I MAP DISCLAIMER r—,,inhf')Of)r_')O1n Tnum of R.rnefahl. AAA All rinhf.roeen�, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 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: Bottom of LC 30' 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 51 Meadow farm Rd. Property Address Douglas Jacoby Owner Owner's Name information is required for Centerville Ma. 02632 11/03/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist. ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Stanton, David From: Schlegel, Frank Sent: Friday, May 17, 2002 9:01 AM To: Stanton, David Subject: RE: another address This is a brand new subdivision. They are"Part of Map 189 Parcel 118.003.The.building numbers assigned to them will be#49 Meadow Farm Rd = lot 7A AND#51 Meadow Farm Rd=lot 7B. Even though you have a#51 in the database, it was for lot#7 which will become invalid for this address when the new parcels.are released. If you try to enter the permit for#51 in your database,the address will change to#49 when the new parcels are updated. It sounds more confusing. than it really is and that's why I wanted to show you how the system actually works!.Call me.if you have further problems with this. -----Original Message----- From: Stanton, David Sent: Friday,May 17,2002 8:16 AM To: Schlegel, Frank Subject: another address Hi Frank, I have another address question for you. I.am.trying to find some time to make.it over to engineering at some point, so you can go over how to find these properties, but we have been really busy here. This is two properties located in Centerville. It used to be Fuller Farms, and is now Meadow Farm Rd.. It is subdivision#777. 1 am looking for address #/Map& parcel information for two properties. They are supposedly lot 7a and 7b. I have found the information on the rest of the properties, but these two seem to be.a problem. They are located next to one another at the bottom of the. circle according to the diagram of the lots we have. Thanks, Dave i � No. �• � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(pplitation for loiopooaY *rae tt Conotruction Permit Application for a Permit to Construct(�)Repair( )Upgrade( )Abandon( ) 5(Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No./L/Eo%galU 1 —+�i�i�f �o. ��/ �2lJ c cW �l 0 o) Assessor's Map/Parce� ^ `� OakaD T> N add 1�� � Designer's Name, and Tel. o.�� . Type o uilding: Dwelling No.of Bedrooms Lot Size 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 7 gallons. Plan Date 7 Number of sheets Revision Date Title -s _j 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 provisi s of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been b Y=oarealth, ! Signe Date Application Approved by Date Application Disapproved for the following reasor6L� Permit No. .a Date Issued Da - -- - ---------------- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS loiopogai *pztemc Conotruction Permit Q k Permission is hereby gM.CoVrAt( ) air �lff). 5g ade( bando1n� System located at t i,• 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 bico pleted within three years of the date of t is pe Approved by i�t. h�/ I Date: r t, Fee k 4 \y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASS CHUSETTS a ZippYicatio'n for Miopozar *Potem Con6truction Permit- Application for a Permit to Construct O Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No.�� �� Owner's Name,Addre s and Tel.No �' �,� N x. Assessor's Map/Paz 1 1� IkAA 0 Ids ljr NN - td arrd�i( Ip��' , `! �. Designer's Name,Address and Tel.No. v I 1'—f�( Type o uilding: Dwelling No.of Bedrooms.0 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow i gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Q 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 provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certifr Cate of Compliance has been ,b � Boaz ealth. Signe L i J Date fd' Application Approved by �"I 1 Date Application Disapproved for the followingrea 0 4 Permit No. ."' Date Issued --------, ----------------------=-------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,.,,MASSACHUSETTS �_. Certificate of Compliance THIS IS TO C R FY,that he Ont 't Swage Di osal System-Constructed )Repaired ( )Upgraded( ) Abandoned b ( ) Y at ha n constructed in accordance with the pr is' ns of Title 5.an a or Disposal stem C n traction Permit No dated Installer .Designer f The issuance of s lfermit shall not be construed as a guarantee that the syste wil c i 7a gned. A�6103 Inspector fk a TOWN OF BARNSTABLE D, LOCATION tn 91V � .�.. SEWAGE # " S VII LAGS c�rf� � lf"f,,ui SSESSOR'S MAP & LOT r 15,9—P3—OC . INSTALLER'S NAME&PHONEn NO. 8/-10v SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -NO.OF BEDRObM'S (h BUILDER OR OWNERCorp PERMITDATE: 1130k I COMPLIANCE DATE: 3 .5- ®3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet . Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by lfl d r Ai ak de ,a o TOWN OF BARNSTABLE LOCATION �0 SEWAGE # ©l� VILLAGE�� i�r (Z��l�,C �SSESSOR'S MAP &is O� INSTALLER'S NAME WPHONE NO. SEPTIC TANK CAPACITY ®� �e4 LEACHING FACILITY: (type) '"' size) a G�•1�.�----.— 6 /// ,NO.OF BEDROWS BUILDER OR OWNER PERMITDATE: 0 COMPLIANCE DATE: PERMrrDATE:___4 S ®3 St-`paration Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by qqqqTown of Barnstable P# Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 Y • BARNSTABLE, ArED MAt�`� Date Scheduled V Time t t o Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: IEL A, G�ALA Vl. ,44� Witnessed By: T_-*?JPJA M J0aA,PJb` lei .: .. LOCATION & GENERAL INFORMATION Location Address ( 4:7 I ­7-A Owner's Name F L�� � FAQ 12 t_Ty r—^itm MEA-pot,J TLO,'YP Address "'�YLVh1 'Cc-NTfYLvILI.E Assessor's Map/Parcel: fv-hr, 6F 18C\/!)(J Engineer's Name NEW CONSTRUCTION REPAIR Telephone# -6 `3 6 Z- y Sy I Land Use 1/IA-C/�-N'7- Slopes(%) D ' �1 Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft ' Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 3 L®T S 3p 6, Ab 351 � cS�so o iFO � � I L,-1A yLlr 01*�, �-,F�� �3 1.0l Ac- ti- T L.- -7 1:� Parent material(geologic) &LArC\.H. 6V11A51N Depth to Bedrock 7-00 Depth to Groundwater: Standing Water in Hole: ey Weeping from Pit Face Estimated Seasonal High Groundwater I TE NATtON OR SI;A ONAL MGM.- tA.-I T,i13 XXX Method Used: Depth Observed standing in obs.hole: NIA in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#_ .___. •Reading Date:.__.—.- Index Well level...--- Adi.factor___ Adj.Groundwater Level /v PERCC}LAT N`TEST pate 7'.1 mT��� Observation ` Hole# ` _7_4?_ Time at 9" �r 4 Depth of Perc @ �" 150 Time at 6" Start Pre-soak Time @ 0-00 �/� o Time(9"-6") End Pre-soak Rate Min./Inch L2 LZ I 5;20 6;k Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) IV Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant l DEEP OBSERVATION HOLE LOG Hole# 1 _. . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel 0- 6Ar 30 G1 ���SAnID 2-s 7/L--1 NO DEEP OBSERVATION HOLE LOG Hole# 'Z--� _. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel 0-- & �L l O`t- 6 -30 Z-5� 6/ . ;DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistenc %Gravel DEEP OBSERV:A.TION HOLE LQG .. Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel Flood Insurance Rate Man: / 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? ES If not,what is the depth of naturally occurring pervious material? Certification q I certify that on A10 V 6' (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 expeerience escribed in 310 CMR 15.017. Signature Date �` i ------------ I Y I lVil)F I)I 6 X 16 PECK p 71 1- 2- Ertl} NO t?, crreEE (41 Al V(X)N1 WALK IN CL05E7 MAST ER BEDROOM SUITE 00, aoreco MASTER DINING;R(Y)m STUDY OATH FOYERFil 7 o C=,T t; T I OFUR fO A"E --------- ---------- IST FLOOK FLAN n n n n n n I I u u n I I 11 n n I n n n n n n n n u n n n II FEN pt7 E�EI. II T(F X 14' ¢zv.' n�¢��_la�.• prt lavv�—w'o z�zu. zw m•' DECK a'o r�ur.' .. .�: �v„• z *r o._JI I II I I��Rn v'�z+m•' II 1„5,,11 11 I II f_ �� II N - - — — — _ — — — — — — Arn crss II F "DAD _ — — — — — — — — - A MASTER e I'I.14 0)M P 1 ° " BATH$Z y WAII,IE BEDROOM A 2 ruxeT b FEN 10 EEL 6N -wT— ALKWAY a LOFT/HOME OFFICE G ,,,. C�ArH '� % an, �nl^ WALK IN 6Ta.. 1 .EnKE ^I Ir• r CLOSET _ I Cr4lR wl VAULTED FROM BELOW 5m 1 � ATTIC.EAVES p rnlw'� ATTIC EAVES b b T F,—.o m•kzoy�zo+�.�_ee ld.J•k_ld.i�6'd�.��5'4�>•r SIrJ�T lT � b 4 b z•d �� r,.o �•la• znw'�no'�z-n v.' w'+mr vo ro 2NP FLOOR FLAN 'i 1'OJw M0. { - odf -.1— N FAOucG 20'14 LABLE AP (RC)87' SJr•0•10'E 470�. F[J`I c SETBACKS: FRONT-30 FT 28'1 `l p0 FT !. {8, IOJ.23' 0'E 219.,. ITOAD. COV T1 MA'1 N001y tot BREAR-1 0 FT l 10)q9 'AGE 273 Qq C0"SEC R; CE 53 �i :'A'Cl'•Utz -525,770 SF 12.07 ACRES) AN�`� /•�.�, / 0 9 iS-475,678 SF(11.25 ACRES)2 ,j N.r / _.''!70'7g•1( 0 0 IS.sY 32 013 SFS 1{SF3 ..y��a?g i iJo.39PPIY' i�0.0 N.60I�'20'E 547 SFS{. ° Y 9 •'S VI KAS BEEN PREPARED ME RULES AND RECUU71.0 i PARCEL A DEIEDSe EFFECTIVE JAN.1,1976 j�Jy�A+. f l NOT bUA B IL ND LOT ry ✓! / 16 •rV J t: 8"A DATE (I.00 ACRES) Il, gZ `y2• ��' i_`3q h� 3 = A(yIN • i '�y1� A ''r7yB\ 4g'7 j1' 9 UFUCN LOT ° %+ _ V.' V } '••R9"g5'o9+ S ol N77-o Jrw to..r, tr ry�7AAA C G G N7r'18'16�W In '.Ng1`I�7 "61'47' i3 11 l fj N77Y5'12w t z 7s.93' 'Je.BJ'�.� '19 II• 4• DPANAGE •7 a���1' 7'Ig.ga' '4� •. /EASEMENT (1.02 ACRES) P.P/A.21.89 - `"y1�' N/^ (I.O2 ACRES)° ^ N)Or J'o1 / y P.P/A-le.w' 11•�8 � r8t (y/..A51f1 i / ID'WIDE so.IJ• .f°1 SLOPE dT 20.11 ! EASEMENT M m I 283'78' I 1�' ; SLOPE WIDE (1.00 ACRES) N 71'43'0{.W EASEMENT )w u ;'�.Ihn,' � SLOPE EASENEM py R-w.00 i V, y 1 20'WIDE i l0T S �•PJ G �-=�—R 10.00 358,72' 1 {{,258 S.F. N 78'J� W iI (I.M 7'06•ACRES) ag'' 1. opc EASEMENT j t06.B9' ^ ^� + •�� 7i LOT q j./„%/o d Jg.\' a S.F. A.15.68• yl H69'S)'S0"W ..'. C'Pb1' .. 4,0 �7i,•(jF ( os ACRES ) JB02'Y� 00. ¢02{•E =,,h,'o w `-�' ? w P.P/A.IB.B{ �w'r'. w•,��� � y' / Lby ,Z� ze r� /N LOT 7 �b 1°/ ^•T 93,71)S.F. ) 21.32' EASE. /.Q.•F/ ,u� 5132'OB'W '7' -M )6.95• NBg.-� 6.60' i/b'\.'� (2.15 ACRES) A. /w,A „ Iy E%STING � �, nM1b. �21•h-..72Jr �'\ `� P.P/A-17.46 — /� DRNNACE ^• �n r TOTAL 7 IF.* : EASEMENT% 09•JJ' UPLAND AREA.N,{97 S.F.2 •/'� _AP'1• ° / TO BE RFTIJOVEO P.P/M18.8 ON 52,{3D S.F.AREA �,'\� O I ------_ HERE* sH+PE _ TO 1�RE .62.43' w I _ SB 1 \TA A0.00 t:2.8j• i o h =y - 1N91' SHAPE TO HERE ,$ TiF. y�6/ P ,F�' '(' AX If 110 BE REMOVED /'\y'E• %, N6¢y31 k.44. 1e RUINS OF �•��. WELL HOUSE Z �l 6�0 y. M31YOB'16-N SO� A 81,216 SO.R. 1 ,�.O 'L 1�'•'Ny I).11' AREA OF UPLAND-6I,2162 i R, N P:)7o 1,y 02 . P-P/A-16.68 ON 1.3 ACRE AREA Jo i/' 6gM1� 1�Oq� _ VION PIPE a4 0` °�•M1M1 -b,(' �'(�� ge i�SM1 FOUND 'y0 ED WETLAND a8A r' �4p FULLER FARMS �.581`72 dI�• N /.AI�'�iYRta /,' IRON PIPE"' LWE7LwD SV8DIVWN/777 '90.4•�� o5}jd y� i ;� vou"o n DEFINITIVE SUBDIVISION PLAN '/,'T6' 77J0 P./0y1`1�,9 6ry0' j/�•l"'I AR L ( BVR�� 7.21' OF LAND IN A to \. AryiO° F(j y ; •`" PPk3CEL BF TO BE COM'El'ED LOT) CENTERVlLLE (BARNSTABLE / "' 9j•l7le�; ?lA' ,•' �� APPROVAL IS REQUIRED .{, JAMES A.JENKViS TRS. 1/ J•^ / 0 JENKeJS NOMINEE TRUST UNDER THE SUBDIVISION CONTROL LAW PREPARED FOR J13, )Q� 9'h0� DEED 1B K.9 994 In gARNSTA LE PLANNIN&OARO 6 w ' • FULLER FARM REALTY P 1 \IRON PIPE �- E.1•-/0• DATEAPPoL 20,.g,:/(j ]It 868'Ig•J1179.63' j ry FOUND REVISED DAIS JUIo '4S A.Y 800 F .% ,P/• Aw ADD PARCEL 8,0 .W VIES A JENKINS,7R5 �.� 1 Jg 2g• JIB i ',y IKWS NOMINEE TRUST I.999{P.III 40 so ngineering, inc. 'al 1 w OF THIS PUN SUBJECT To A COVENAN TO BE RECORDED HEREWM. ✓ /✓/�y 1 f .�AM L LWPA HUTCHENRIDER,CLERK OF THE TOWN 0/B RNSTABLE,CEITM THAT ME 1 (L ENGINEERS �\•�. NOTICE a APPROVAL OF THIS PLAN WAS RECEIVED AND RECORDED IN TNIS OFFICE I�` AND THAT NO NO710E Of APPEAL WAS RECEIVED WRING THE TWENTY DAYS NEXT / D SURVEYORS \ FOLLOMNO ME RECEIPT AND RECORDING Of SND NOTICE J irmouih, ma OZ675 iP"sDe w1°22-vaxeo I `.. � L?,►Y-)i, a.�. TE TOWN CLERK I • j 4 Z TEST HOLE LOG DATE: DULY 11, 2000 P-9799 SOIL EVALUATOR: D. OJALA 44 WITNESS: D. MIORANDI PERC RATE:, < 2 MIN./IN. 48.0 / 0" 48.0 0" Ap SANDY LOAN AV SANDY LOAM I0YRS/3 10YR5/3 47.5 6" 47.5 6^ / l B LOAMY SAND B m LOAM SAND {�� 2.5Y6/4 2.5Y6/4 /' ✓o 45.5 30" 45.5 30" C a MEDIUM TO C = MEDIUM TO COARSE SAND COARSE SAND / 2.5Y7/4 B 2.5Y7/4 6" O., l / ( 7,q 35.5 150" 36.5 138" , ,0�3 NO WATER ENCOUNTERED NO DESIGN DATA J \`� �• DAILY FLOW: (4) BDRMS. x 110 GPD = 440 GPD SEPTIC TANK: 440 GPD x 200% = 880 GPD USE: 1500 GALLON PRECAST SEPTIC TANK LEACHING FACILITY: USE: (3) 500 GAL. PRECAST DRYWELLS LINED WITH 'gaLtv A 4' OF DOUBLE WASHED STONE CAPACITY r �-- SIDEWALL: 93 x 2 x 0.74 = 137.6 BOTTOM: 13 x 33.5 x 0.74 = 322.3 / \ TOTAL: 459.9 GPD 44- NOTES,: 1. ALL PIPE TO BE 4" DIA. SCH 40 PVC. 2. PIPE TO BE LAID LEVEL FOR 2 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. 10 \ .. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED �" SSS� 4 �? ON A 6" LAYER OF STONE. qNp 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2" LAYER OF 3/8" PSASTONB OVER --------------------i ;4"-lk" DOUBLE MRSNED STONE _____________________ ALL AROUND TOP OF FOUND. + @ ELEV.�`jD,a _______ ______ rTOP 2 F.L. 45.7 47oo ZS 9G.00 4;.B3 0 t3c;gTuq e-F.L. 43.0o SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN FOR GENERAL NOTES LOT 7A FARM MEADOW ROAD CENTERVILLE , MA 1. CONTRACTOR TO BE RESPONSIBLE FOR TEE LOCATION OF ALL UTILITIES, ABOVE AND UNDERGROUND, PRIOR TO ANY EXCAVATION OR CONSTRUCTION. a PREPARED FOR 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE iTITH 310 CMR 15. 00: TITLE V. SEMINARA CONST . CORP . 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. DATE: DULY 16, 2001 SCALE: 1" = 40' 4. ALL DISTVRBBD AREAS TO LOANED AND SEEDED. 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES 1645 FALMOUTH RD. - SUITE 4C P.O. BOX 417 CENTERVILLE, MA 02632 TEL: (508) 775-0735 FAX: (508) 775-0754 APPROVED BY: _