HomeMy WebLinkAbout0191 MONOMOY CIRCLE - Health 191 MONOMOY CIRCLE, CENTERVILLE
A= 191222
0
II
e
E
4
UPC 12534 '
No.2153LOR
HASTINGS,MN
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address Pam+
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name z
information is
required for every Centerville MA 02633 September 27, 2017
page. City/Town State Zip Code Date of Inspection Sr
+:amy
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
�y Company Name
155 George Ryder Road South
+ Company Address
Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system_ inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes jHOFQ4 ❑ Conditionally Passes ❑ Fails
El Needs er E IuuRatio the Local Approving Authority
OUGHA WR N
No 28
9P September 27, 2017
Inspector's Signal FM /NgPE Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
` ****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
G�j� vs
S y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is Centerville MA 02633 September 27, 2017
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes::.
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
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 th.esg"tic tarik(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltratio,or tarikrfailure,,s imminent. System will pass
inspection if the existing tank is replaced with a complying septic taA as approved by the Board of
Health.
tA \,6.
*A metal septic tank will pass inspection if it is structurall' Siound;not�leaking and if a Certificate of
Compliance indicating that the tank is less'than 20';�years'old;'is,.available.
❑ Y ❑ N ❑ ND (Explain below): '"
t5ins.doc•rev.6/16 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
,^M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is P required for every. Centerville MA 02633 September 27, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms aired.
are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is required for every Centerville MA 02633 September 27, 2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less"than 5 ppm; providei that no othei`failur8`"C`riteria 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.doc•rev.6116 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
;M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address _.
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is p required for every Centerville MA 02633 September 27, 2017
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
❑ El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees.
Owner Owner's Name
information is required for every Centerville MA 02633 September 27, 2017
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the followinghave been done. You must indicate"yes" or"no" as to each of the following:
Y
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): n/a Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a - no plan
t5ins.doc•rev.6/16 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
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is required for every Centerville MA 02633 September 27, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
No design plan was found at town offices.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes N No
Water meter readings, if available last 2 ears usage d 650 gpd
9 ( Y 9 (gpd)):
Detail:
2015: 239,000 gallons 2016:236,000 gallons NOTE: Irrigation system in use!
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees '
Owner Owner's Name
information is p
required for every Centerville MA 02633 September 27 2017
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: owner
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.doc-rev.6116 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
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is Centerville MA 02633 September 27, 2017
required for every P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age unknown—system is assumed to have been installed at time of dwelling's construction in 1975.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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:):
No evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 8.5'x 5'x 6-1000 gallon
Sludge depth: 4 inches
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is required for every Centerville MA 02633 September 27, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle Winches
Scum thickness 1 inches i
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined?
Previous inspection report
p p
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year
round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence
of leakage in or out was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
_ Distance from top of scum to top of outlet tee or baffle .
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 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
41M Sy`eV 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is Centerville MA 02633 September 27, 2017
required for every P
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.doc-rev.6/16 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
^M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is
required for every Centerville MA 02633 September 27, 2017
page. CitylTown 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
at outlet invert
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.):
No adverse conditions observed.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
_ If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 191 Monomoy Circle_ Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson,Trustees
Owner Owner's Name
information is p
required for every Centerville MA 02633 September 27 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1, 20x30 appx
❑ 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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching field stone and no effluent contact staining was observed in
the stone or overlying soils. Standing effluent was observed at a depth of 5 inches below the top of
the peastone layer.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 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
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is required for every Centerville MA 02633 September 27, 2017
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is p required for every Centerville MA 02633 September 27, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
SEPTIC INFO AT
LEACH FIELD p
LOoC A VOoNISS
—OF SEPTIC COMPONENTS
—DISTANCES„IN:DECIMAL FEET
A 8
3 1 36 24
2 36 29.5
O* 2 3 38.5 28
��� 1000 GALLON
A SEPTIC TANK
I
THIS SKETCH IS
BEST VIEWED IN
g COLOR FORMAT
EMSVnNG
DV�/1 WELL We
NOT 0 1191
TO
SCALE
z s J ..
Lu
Q
3 508 364-0894
LMIOo nN1Oo LMIOo Y C #R C L E
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is p
required for every Centerville MA 02633 September 27 2017
page. CitylTown 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: more than 6.7
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:
previous inspection report
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
An inspection report of 5/14/1998 referenced a hand augured test boring that showed no groundwater
at three feet beneath the bottom of the field. Applying a retroactive groundwater adjustment of 0.3
feet(Index well SDW-252, zone D, May, 1998 reading =45.98) demonstrates that the bottom of the
leach field is above the adjusted high groundwater elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 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
191 Monomoy Circle Assessor's Map: 191 Parcel: 222
Property Address
Monomoy Circle Realty Trust, Walter and Frances Jacobson, Trustees
Owner Owner's Name
information is p
required for every Centerville MA 02633 September 27 2017
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMNIONN%T ALTH OF MkSS ACHL•SETTS
FAECLTIVE OFFICE OF FNNIRONMENTAL AFFAIRS
DEPARTMENT OF ENNIRON;IE�TAL PROTECTION
ONE WINTER STREET. BOSTON. At.r. O.ICcS bl -_S_•E�C�G`
' V
•e. �,
I
• HFglTf6g9Nsl 98 7-RLmm-Cc
VvILLIAM F.WELD
ARGEO PALL CELLL'CCI . . , -�a •� :4 'ID B S T RL
1_LGOVCmo[ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j '' Conurissic
(� ii 1�1 PART A "' '' -. _ • .:
CERTIFICATION :. . .: . . .. ._.
Property Address . -.:c;: a�
; i
•(if difiereni) 13 �ao:3'�� '-`1
Date of Inspection: 1�
Name of Inspector. �� k 74p 1 E���� - • �-�S�O�.T �,II{�
am a DEP ap roved system inspector pursuant to Section 15.340 of Title 3 Q10 CMR 15_0001 '
Company Name: � e ���-r'e E-n A -r'r�., V" i—
Mailing Address: 2 o /�Q� ' ��� H fJ-SNOPe_L /->' �0
Telephone Number: _fZ
CERTIFICATION STATEMENT
I cer:t{� that I have pe•sonall� ir.speeed the sewage
disposal System -, this addiM and tha: the iniorrration retorted be:oM is true. accura
and como(ete as of the time ei inspe:•o-. The insCe::o•i Na: pe-crme: base= on my training and experience in the grape: fur:e,cn anc
maintenance o.*on-s-te sewage disposa: sy'Sterris. The m.%erm _
Passes . . � • .
_ Ca tc,t-o^ail. Passes
_ Neec; Furthe• Evaruatio, Ey the Local Approvtng Authoi`M ' .
Fa.
Inspector's Sigrtatur Date:
T;te Svs:e— Insze o• sha'' submit a copy of this inspect,an recce to the AFcrcving Authcnty within thin— (30, days cf completing this
inspection. It the s\-stern is a share--: systern o• ha= a desig, no,,. c: 10.000 gcd or e,e3te-, the inspector and the sys;e-r. owner sh it su' rn
ice of the Depa-ment c: Envircnmenta' Frcte'n ccr.. The crig!na! should be se-it to the system cN
the repo- tc the aparopnate reg,arat o
and copes s-n:to the buver, if applicable, and the apvcving authorin
INSPECTION SUMMARY:'. . Check A, B, C, or D
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates an}• of the failure criteria as define,' in 310 CMR 15.3(
' Any failure criteria not evaluated are indicate: below.
COMMENTS: ,
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The systern, u
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y. N, or ND,. Describe basis of determination in all instances. If'not determined',explain why no�
The septic tank is metal, unless the owner or co-ator his provided the system inspector with a copy of a Certificate o
Compliance (anachedi indicating that the tank was Installed within twenty (201 years prior to the date of the inspectior
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfilmition. or t
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic r.r
w approved by the Board of Health.
SUBSURFACE SE1h'AGE DISPOSAL SYSTEM INSPECTION FORM
.. . . _.... ._. •....PART A:;•::^ ' . . . . .. ,.. '
CERTIFICATION (continued)
-
Property Addrass:
Owner. 4
Date of Inspection:
ej SYSTEM CONDITIONALLY PASSES lcontinu,�d _
~ Sewage backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, Sealed cr uneven distribution box. The system will pass inspe=lion if(with approval of the
Board of Healthl. Describe observations:
broken prpe(s) are iepiacrd _ ;�. .. . . ._ - .• •- - :
-.
obstruction Is removed R!• :
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe!sl.:The system will pass
inspection If twith approval of the Board of Health):
broken pipetsi are replaced
obstruction•. is 'removed
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEkLTH: -
Conditions exist which reouire iurthe•evaluation by the Board of Health in order to determine if the system is failing to prate:'
public health• saien,`and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HE-kLTH DETER.MINE5 THAT THE SYSTEM.{ 15 NOT FUNCTIONING iN A MANNER
WHICH WILL PROTECT THE PUBLIC HE.kLTH AND SAFFE Y AND THE ENVIRONMENT.
_ Cess000l or pri.ti is within 50 fe--t of a suriace water -
Cesspoo! o- pn.-.- r: v.ithin 50 feet of a bordering vegetate-d wetland or a salt marsh. _
2! SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (A-NO PUBLIC WATER SUPPLIER, IF APPROPRIATFi DETERMINES 7F
THE SYSTEM 15 FUNCTIONING.IN A MAti1ER THAT PROTECTS THE PUBLIC HEALTH AND SAFFE Y A.ND THE
ENVIRONMENT:
_ The wstem has a septic tank and soil absorpticn system (SAS, Ind the SAS is within 100 fe•e:to a surface water suppl}
tributary to a surface water supoly.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I o(a public water supnty we!1.
_ The syste-n has a seppc tank and soil absorption system and the Sk5 is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less thar. 100 fee, but S0 feet or more from a
private water supply well, unless a we!I water analysis for coliform bjcteria and volatile organic compounds indic3tes
the we!I is free from pollution from that facility and the preserta of ammonia nitrogen and nitrate nitrogen is equal t
less than 5 ppm, Method used to determine distance (approximation not valid).
3) _ OTHER
t:...i..a o�tzs�s-t t•.Q. � or is
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART B
CHECKLIST
Property Ad cess:
Owner: bup.�
Date of nsPeclU n:
Check if the following have been done: You must indicate either 'Yes' or *No'as to each of the following:
Yes No Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection.
�As built plans have be*e,n ob:amed and exarnined. Note if they are not available with N,A.
_ The iacai-.� or.dµelling vas inspected for signs o-sewage back-up.-
The systern does not receive non-sanitary or industrial waste flow. '
The site µas inspected for signs of breakout.
_ All !vste-r. co-nponent:. excluding the So-[ Aosorpuon System, have been located on the site.
_ The septic tans: manholes µere uncovered. opened. and the interior of the septic tank was inspected for condition of
baffles or tees. materta? o'construcoon. dimensions, deptn of liquid, depth of sludge.depth of scum.
The size and locat-on of the Soil Absorption System on the site has been determined based on-
_ The iac,I-t, o%%ne- ,ano occupants. t:dirteren: from owners were provided with information on the proper maintenance of
1I� Sub-Suriace Disposal Systern.
Existing tniormation. Ex. Plan at B.O.H.
_ Determined to the field r,•an,, of the failure criteria related to Pan C is at issue, aaproximat,on of d,s:ance is
unacceotabie (15.302.31:bIl
(reviped 04/25/S71 l&4*'4 of 10
SL:BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addr,-ss: r
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either `Yes' or'NO as to each of the following:
more
ng:
1 have determined that the system violates one or more of the following failure criteria a< defined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged 5A5 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.
Sta,ic Irauid level in the distnbition box above outlet invert due to an overloaded or clogged SkS or cesspool.
Lreurd depth in cesspool is less than 6" below invert or available volume is less than 1/2 day tlov.
Reou;red pumping more than, 4 times in the last year NOT due to clogged or obstruc ea pipes .
►cumber of times pumped_.
An...portion o°the Soil Ansorption System, cesspool or privy is below the high groundwate• elevation
Am' portion o:a cesspool or priVy is withir. 100 feet of a surface water supply or tributary to a surface water supply.
._ Any potion of a eess000' or.pri%� is within a Zone I of a public Weil. _.
An% peso-• o:a cesspool or pri%-v is within 50 feet of a private water supply well
Any poi,or. o a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv well with no
acceo:able Ovate, quality analysis. H the well has been analyzed to be acceatabie. attach copv of well water analysis for
cohiorm bacteria volatile organic Compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: :
tou must indicate either -Yes` or 'No- as to each of the following,
The folio-rig criteria aoP to large systems in addition to the criteria above:
The system serves a facilin with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safer) and the environment because one or more of the following conditions exist.
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such systerb shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 C&1R 5.00 and 6.00. Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.I�t
PART C
SYSTEM INFORMATION
Propert% AddressM t %O+130N101LA 'f-y►III:—
Owner:
Date of Ihspection: y'
FLOW CONDITIONS
RESIDENTIAL:
Design t1oN' ?�h e.p.d./bedroom for S.�.S
Number of bedrooms
Number of current residents-,
Garbage S-v der (yes or nol:,--p)-
Laundry connected to system (yes or no!. - _- ----- • -
Seasonal use tyes or no::�
Water meter readings, if av table (last two (21 year usage tgpd):
Sump Pump Ives or nor
Lai:date c'occupancy MX1nz Q��uc-ta�~'�► '�)
COMMERC lA.L'INDUSTRIAL•
Type of establishment
Design fio%%-_yahonsida,
Crease trap present Ives or no_
Industrial %%aste Holding Tani; present. Ives or no— - -
':on-sanitar, %ante d-scnargec to the Trje S sys;em. tves or no
dater meter readings. d availabie
Las*Pate o: o c,;;anc.
OTHER: .De:cnbe
Last pate or occooanc.
GENERAL INFORMATION
PUMPING RECORDS and wce of information
... _.. .. .tit �_ . _ •
S)-stem pumped as par, of inspection: tves or no.tLo
If yes, volume pumped eallons•
Reason for pumping
F SYSTEM
Septic tank/distribution box,1soil absorption system �
Single cesspool
Overflow cesspool
Pm�•
- Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: y��
Sewage odors detected when arriving at the site. (yes or no), iz
.. .' i ,.:JAI�;_..,.-• ,r ii�'!:7 '.
SLBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 A)fJlAllp��
Owner: �RkO 1 l
Date of inspection:5I L1�t
l
BUILDING SEWER: �(l
(Locate on site plan) "v 7 77
Depth below grade.
Material of construction: _ cast iron _40 PVC _other (explain:
Distance from private water supply well or suction Ir-:
Diameter
Comments: (condition of joints, venarig,evidence of leakage:�eic:l __. .:: :
i
SEPTIC TANK:
(locate on site pli's
_....
Depth below grade�Q Polyethylene _othenexplam
Material of construction: Aconcre:e _me:a _F�oerg,a.. _
If tan►, is me:al. Ifs:age _ Is age con?irmec o� Cen;fica--e of Compliance _(yes"No
Dimensions
Sludge depths p._..
Distance from top o- s!udee to borom o: outlet tee o• ba le-%)_
Scum thickness ()it
Distance from top of scum to top o'outle.-tee of bale "?j--_- ►1
Distance irom bottom of scum to bo-o-n o,outte: tie c• bane _]_q
How dimensions Mere determined
Comments,
trecommendation for pumping. condition o� iniet and et tees or baffles. depth of liquid Level in relation to outlet inv structural
integrity, idence of leakage, e:c.t t t
L-A r,t DA Alz
GREASE TRAP:
(locate on site pl ,
Depth below grade: -
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:
Comments:
(recommendation for pumping, condition of i!1let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity. evidence of leakage, etc.)
(revised 04/25.17) Page 6 of 10
TOWN OF BARNSTABLE
LOCATION k�k IlAot,4 mo vi C�Q-- SEWAGE #
YiLLAGE &"x;L"k ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY S QCX9 a.Vr
LEACHING FACII.TTY: (type) T ISAA (size) Y, 2e7
I NO. OF BEDROOMS
BUILDER OR OWNER 15
—F&VAT DATE: � Coe) COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility N Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) . �` Feet
Furnished by
� .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
MOW SYSTEM INFORMATION (continued)
Propenq Addres : 4 l MOW 140
Owner:
Date of Inspection: C''�'�C_ _• - J - - • • r -
TIGHT OR HOLDING TANK:;': w 'Tank must be pumped prior to, or at time, of inspections
(locate on site plan,
Depthbelow grade:__......__..._.___�____..._..-------___._-------.._----.-----.--.___._._-•-.----...._._._..------..__.....__.._..... .. . _
Material of construction.-' concrete _metal •_Fiberglass _Polyethylene :. other(explain) - - - - - —
Dimensions: ---
Capacir•- gallons —
Design flow
Alarm level A:arm in working order— Yes. _ No --" -' - -
Date of previous pumping
Comments _... - - ..._.._. ... - -._... ..
(condition of inlet tee. condition o• a'a•rr, and float switches. etc.) - ---
DISTRIBUT10% 6001t�
(locate on site pia- 1
Death of houid level aoo\.-e outlet tn.e^ will OUT?z -.tw,g�
Comments
t of if level and distribution. is eau evi ^ce of solid carrno er. vidence of leakage into or out f box, etc.(
PUMP CHAMBER:— -
"(locate on site plan.-
Pumps in working order: (Yes or No•
Alarms in working order (Yes or No.
Comments: ....._..---__._.._.. ...... . ._.__. ..._.
(note condition of pump chamber, condition of pumps and appurtenances,-etc.)
i
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr-ss:
Owner: v
�1 sb
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_wS
(locate on siteplan, if possible: exca-- tion not required, but may be approximated by non-intrusive methodsi y
If not determined to be present, explain:
Type: -- - -
leaching-pits.number._
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,tength: 1
leaching fields, number, dimensio^s ,f�Q�-- - -OJl20
overflow cesspool, number --
Alternative system
Name of Tecnnotog\-
Comments.
to to condition of soil, s1 r.s f hydraulic f dure. I ve' of on4in on ion of vegetation, ew .► - -
CESSPOOLS: 1\)
(locate on site lar`b
Number and configura;.on
Depth-top of liquid to inlet Inver,
Depth of solids lave-
Depth of scum layer.
Dimensions of cesspoo:
Materials of constructior -
Indication of groundwate
inflow• icesspool must oe pumpeC as par, of inspection
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.)
(revased 04125/91) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued
Propert} Address: �Cj` 40 klC MO L
Ow ne►:����ji11L� \ .
Date of Inspection: Clet
SKETCH OF SEWAGE DISPOSAL SYSTEM. J
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
71V �Cj t
1: z
y
.
to `
63 - 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addres,-• Alt #1014-0111- �
Owner: XA1 iSbVR-
Date of Inspecuon:
1
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:,_
Obtained iron Design Plans on record
Observation o`Site (Abutting property. observation hole, basement sump etc.)
Determine it from local conditions
Cneck %+rth loca! Board o• neater
Check FEMA Maps
Check p-imping records
Check local excavato•s tnstalle•s
Lse LSCc Da-.z }
4
r•
Describe in you, o%%- %tioros r.o•.% %o:. es:ao the High Groundwater Elevation. (Must be completed:
"I, yvlc 7' /x WA-� —t3:5-(T6w\- c>4- F14-1d A-T-
(rev-sod 04.125,9-. F&9% 10 of 20