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HomeMy WebLinkAbout0305 MONOMOY CIRCLE - Health 3"-5 Monomoy Circle . Centerville F A= 190 201 �•llll �J�QE�Y��o�o UPC 10259 No. H163OR nNB�� HASTINGS, MN r `\q V 4 �V W Il 1� QO � M N LA 14 er f � r Z G c Commonwealth of Massachusetts �n Title 5 Official Inspection Form rm h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor , Owner Owner's Name information is required for every Centerville Ma 02632 10-25-2019 page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �/# filling out forms t a33 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 ua Company Address Sandwich Ma 02563 10 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true,.accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 10-25-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 1 c Commonwealth of Massachusetts Title 5 Official Inspection Form col Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle V Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ■❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments + � 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owners Name information is Centerville Ma 02632 10-25-2019 required for every 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 ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection; Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ O 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 Commonwealth of Massachusetts �- Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle —u Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O 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. ❑ El 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 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 t 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. ❑ El 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form m gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `............ 305 Monomoy Circle u Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? x Has the system received❑ ❑ normal flows in the previous two week period? p p ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ 0 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: 0 ❑ Existing information. For example, a plan at the Board of Health. . ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle V� Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 91 No Does residence have a water treatment unit? ❑ Yes ro No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): See below Detail: 2018- 9,000gallons 2019- 12,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: 8/2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �m Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle u% Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Owner- date of last pump is unknown information: Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: 2002 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 H 40 PVC ❑other(explain): Town water 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 Forth:Subsurface Sewage Disposal System-Page 9 of 18 c� Commonwealth of Massachusetts �m Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' 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 1 Dimensions: 000gallons 4" Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form ±= R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle V Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in workingorder: 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): 0" Depth of liquid level above 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Chambers were dry when viewed. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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 �^ Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle V Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town . State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA 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 305 Monomoy Circle u% Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately II l.ocA,-noN 3 0 .yf[ram( g y C 1 h' SEWAGE# C7 c> .,r rj vn.7:Ai�z�.�'��'..�::7�,.",��lr!'.;..�1..�" s� �sissax•s i��Ar.�. :c�T 1��'-.2b;t tivs rAL F ZVS NAAF A,r>HONE. ko; _[ :.r s4 'ca 1 Z. ,s c a✓ . SE!, tc TArrx cArAcrr-sr,..l 6"fa o - Ir' ;EACr TNG FAcu.;;r rY try )., ..:... 1�,y zL�.+211= teazel -5 A . NO.OF 8Er)R()0MS.,__� - BuiLDEft"OR OWNEtt i o•Iwe.ti. PERhdrrr)ATF.,__ r' v , Separatinn:C)is;�nre Bctwrzn;:ihe: . Maximur ::Adiusted;C;ruu»dwutrr Tiiilis,co the i3t ctx�r�-r 1 Leaching F nslgty w. __ cet Private water Suirtily"Well:and'Leaching Faci.Wy (rf any wells exasz on.s"sttljr within 2W,feet of.lewbIng-Yaeiilty} r eet E".of Weiland arxa,:Leaching,Facility fii w%y wetlands exiyt. within 300 fect.of'leaehing facility) Feet Furnished b r E. r s 5,. s Yttu ✓M. C,i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �T Title 5 Official Inspection Form +' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle V Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: 0 Check Slope IWE Surface water IWE Check cellar n Shallow wells Estimated depth to high ground water: No GW @ 126"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 3-11-2002Date ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. 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 c� Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 305 Monomoy Circle Property Address Thomas O'Connor PR of Lorriane O'Connor Owner Owner's Name information is Centerville Ma 02632 10-25-2019 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed 0 D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included R' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE �L `LOCATION 3 ® S 7 /y( O/1/0 �{?O�y C/IQ• SEWAGE #� OD�,"A VILLAGE ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME&PHONE NO. / W ACC)/j'l P3 E' Z ?' S O�✓ SEPTIC TANK CAPACITY / © 00 - _a L ,V LEACHING FACILITY: (type) m 40A (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: D 2 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 at r �� $50. 00 No. ©` Fee THE COMMONWEALTH OF MASSACHUSETTS 1 Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0ppYicatiou. for Migogar *pgtem Conotructiou Permit Application for a Permit to Construct( )Repair X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 305 Monomoy Circle Owner's Name,Address and Tel.No. Centerville,Mass . 02632 Claire Colwell , Assessor'sMap/Parcel II D7_0 305 Monomoy Circle Centerville ,Mas . 02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. r J.P.Macomber & Son Inc . J. Doyle Associates P.O. box 595 Box 66 Centerville ,Mass. 02632 W. Falmouth,Mass . 02574 508-563-199 Type of Building: Dwelling X X No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder�0 ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 5 5 gallons per day. Calculated daily flow 3 X 110=3 3 0 gallons. Plan Date 3/12/0 2 Number of sheets Revision Date Title Size of Septic Tank Existing 1000 Type of S.A.S.Existing 1—LP-1000 Description of Soil Sandy loam 0"-3" Loamy sand 3"-32" Medium sand with 15% gravel . 39"-126" Nature of Repairs or Alterations(Answer when applicable) Adding 2—5 0 0 gallon leaching chambers packee in 4 ' of 12" stone . With 3/8" stone cap . 25 'X12 ' 10" by2 ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has beeAthefollowing this ar f th. Signe o Datefl /2 7/0 2 Application Approved by Date Application Disapproved reasons Permit No. D csn Date Issued 2 BARNSTABLE, MASSACHUSETTS i Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )RepairedNXX)Upgraded( ) Abandoned( )by J.P.Macomber J r. } at 305 Monomoy Circle Centerville,Mass. has been constructed in acco dance with the provisions of Title 5 and the for Disposal System Construction Permit No. 'a�dated CA o� �6Z . Installer J.P.Macomber & Son Inc. Designer J.Doyle Associates 1 li The issuance of s pe t shall not be construed as a guarantee that the syst6n..will€u do s-J'esigned.mi Date r'� i Inspector 1 f ---,, --------`--------------------------- r No. //t��r—/ Fee50.00 1 THE COMMONWEALTH OF MASSACHUSETTS j i PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �Digaaf *pgtem Construction Permit Permission is here b granted to Construct( )Repair X�Upgrade( )Abandon( ) System located at 3y05 Monomoy Circle Centerville,Mass. r r 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:Constructio must be completed within three years of the date o rthis mermit. ��Date: l�0 �`� � l C�� Approved by �" 4 r �, C�jj -c�ri� f� $50.00 ` No.r +` E' ., Fee i T1iE--�O`MMONWEALTH OF MS CHUSETTS Entered in computer: - � { .Yes PUBLIC HEALTH DI�/ISION -TOWN O SETF BARNSTABLE,, MASSACHUTS t, 01ppYication. for Migogaf *p.5tem Con5truction 3permit Application for a Permit to Construct( )Repair`,X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 305 M o n o m o y Circle Owner's Name,Address and Tel.No. — Centerville,Mass.02632 Claire Colwell 1 Assessor'sMap/Parcel 305' Monomoy Circle Centerville,Mas. . 110 02632 Installer's Name,Address,and Tel.No. 5 0 8—7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. �. J.P.Macomber & Son Inc. J. Doyle Associates P.O.box 595 Box 66 Centerville,Mass.02632 W. Falmouth,Mass.02574 508-563-199i Type of Building: j Dwelling XXNo.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder V0 ) i Other Type of Building No.of Persons Showers( ) Cafeteria,( ) Other Fixtures i Design Flow 3 5 5 gallons per day. Calculated daily flow 3X 110=3 3 0 gallons. Plan Date 3/12/0 2 Number of sheets Revision Date Title - I Size of Septic Tank Existing 1000 Type of S.A.S.Existing 1-LP-1000 Description of Soil Sandy loam 0"-3" Loamy sand 3"-32" Medium sand with 15% grave1.39"-126" Nature of Repairs or Alterations(Answer when applicable) Adding 2—5 0 0 gallon leaching chambers packee in 411of 11" stone. With 3/8" stone cap. 4 25'X12 ' 10" ,by2' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue6by this B"Oardfof ealth. r Signe/d _ t i Date6/2 7/0 2 . Application Approved by f rr 0 Q C \�l s ►`.. Date Application Disapproved fore a following reasons i Permit No. C��"� ' a� Date Issued ——————————————————————————————————————— T.41!I�..,L On FA PA PrL&lSA L�,,v...re�.nA .. nn 4:....1,4..,L.G`r- .-.. G_.._.. r TOWN OF BARNSTABLE L LOCATION 3 O / y O ' SEWAGE VILLAGE C��(O�Q/� V 1l� ASSESSOR'S MAP & LOT — I INSTALLER'S NAME&PHONE NO. J P AA A d ISEPTIC TANK CAPACITY LEACHING FACILPI Y: (type)--T NO. OF BEDROOMS BUILDER OR OWNER Co IT � 2 : d-V u'2-' COMPLIANCE DATE: PERMITDATE Separation 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 i I v 4�° COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 305 Monomov Circle Centerville, MA 02632 Owner's Name: Claire Colwell Owner's Address: Same Fp,�1.ED r6� Date of Inspection: December 17, 2001 l RECOVER Name of Inspector: (Please Print) James M. Ford Map: 1�90 Company Name: James M. Ford Parcels 201 200� Mailing Address: P.O. Box 49 LAN " 2'Osterville.MA 02655-0049Tele hone Number: (508) 862-9400 OF BARtiSTABLEP EALTH DEPT. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Ne s urther Evaluation by the Local Approving Authority ✓ Fai Inspector's Signature: Date: December 26, 2001 The system inspector shall submit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 305 Monomoy Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. A 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 305 Monomov Circle Centerville, AM Owner: Claire Colwell Date of Inspection: December 17. 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] Yes (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000- 78,000 gals.; 1999-86,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped in Spring 2001 -per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Apr. 23180-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 BUELDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage The inlet cover was 10" below grade. GREASE TRAP: None (locate on site plan) 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 305 Monomoy Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: None (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.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6' - 1000 gal. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The liquid in the pit was above the inlet pipe. The pit was in hydraulic failure. The cover was 2'below grade The bottom to grade was approximately 9'. CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: None (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.): 9 •• Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 305 Monomov Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 Map: 190 Parcel. 201 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �Gk Qi- 99.( a O 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 305 Monomoy Circle Centerville, MA Owner: Claire Colwell Date of Inspection: December 17, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30'+/- feet (Adjusted High Ground Water Level is 25.0) Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 30'+/-to groundwater at this site Using the Cape Cod Commission Technical Bulletin, the high ground water adjustment for this site(SDW 252 Zone D 11/01) is 5 0' This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 i Ge-A de. aS.0 q GroindwAlf" leVe 0 G rovAC�WA7t r I eve, I n if M 3D5 � f:7�c5n s 9 rev f��r�� sf�I�'7�t711/ t�SVAr,--- a �` r Y T } w� ' �� �^ t 14� � �� �+ �- , key 'bte- ., ��.. �, r - ✓r � 7� •. _. ^' „ 'RY..��. - LO CAMI.O K—A SEW- -Q-G,.E—RER-MIT U Q. _ 43_HonomoY CIr_eI V 1-L-t~-h-G►E— _ - — — - -_- _ Center_v-11.1e _ _ — r _ _Delta Crane Service off Airport .Rd. Hyannis, Mass. 75-U IL-D E-R-S—IJ-/�►�1-E—�—A D-D-R-E SS Alan E. 5�11, Ina. _ Box 536 Centerville, Mass. DQ"CE_P_ER_tAl-T D AT_E—C.Q M-P_L_MMs CE—I_SS-U ED �L26�4 l N0� f No. il --------- - - FRic .I ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA TH Appliration for Dhip fiat Morkii C owitrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal t: _06� d7o Sys.. .-a060*_dlool -----------"�.�-'"------------------------- ------------------------------------------------------------------------------------------------- �� Lon•_Add re i+eseP CD or Lo No.��/�'O�s ......................... . ...... .................. ......----•-.... .......................................... Owner ----•--•------------------•.................Address wfD_0. -;;�77 .�" Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a, Other—Type of Building ---------------------------- No. of persons.--__----___-_-_----_---_- Showers ( ) — Cafeteria ( ) a' Other fixtures w Design Flow...........................................gallons per person per day. Total daily flow-----------------------------_--------------gallons. W . Septic Tank—Liquid capaciti gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width___ ___________ Total Length.................... Total leaching area--------------.-----sq. ft. Seepage Pit No............ .. Diameter.................... Depth below inlet.................... Total leaching area.----_.--.---_---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) r a Percolation Test Results Performed by--------------............................................................ Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..------------------_- s Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water--...._-___-.- .---_-_ 0 Description of Soil....19,46 a ------------------------------------------------------------------------------------------------------------------------------------- x w V Nature of Repairs or Alterations—Answer when applicable----------------------------------.--_._.--._-----.-----_------_----------.-.---_--.--.----:---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned f rther agrees not to place the system in operation until a Certificate of Compliance has been i su d by the board of hAalth. / gne1.... . ......... --------•• �� ���----•-• D e_ Application Approved By----------- . ............. ------- - � �- - -- ----------- ..... ... .. .... 7 , Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---•---------•------•--••-••-------•-•••---•-•---•------------•-••--••----------•------•--•---•--•------------------------------------------------------------------------------------------------------ Date Permit No........................................................ Issued------. =l --•------. Permit No......................................................... _ Issued.•--- Dae .. la ' THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEALTH g �..........................oF.................- .:..................................----------............ Trrfif irate of Tomptiattre THIS IS TOG TIFYr at the Individual Sewage Disposal System constructed (" ) or Repaired ( ) - �' Installer .................................................... has been installed in accordance with thkProvisions of Article XV of�The State Sanitary Code.avdesc�i-ibY in the application for Disposal Works Construction Permit No............I___________________________ dated_---____:�____/` � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.......... -•---•------•------------•---•-•---------•--•--•••-•-•••--••-•-•---••-••- THE COMMONWEALTH OF MASSACHUSETTS BOARD O,F HEAL-T-H ........ .... ..... of.......... No. .................... FEE....................... Permission �reby granted--- ,� _w�G�"} /� = �.... z.................................................... to Construct or R= air # an Individual Sewage D'posal Syst n , Street, 1 as shown on the application for Disposal Works Construction Permit No..__12/A __fit. Dated_______________ __ __ __________ Board H DATE of ealth FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No......................... Fmc.....LAI................ THE COMMONWEALTH OF MASSACHUSETTS -I—, ,: .- BOARD OF H E A T H _t. .C 4�*. . ..--.OF.--........ ✓_M.. .. '�'�-� %s ...... ... ApVtiratiun -for :41,4Vufitt1 Workii Tnni#rnrtion PPrnait Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --------------------------------•-•-----•••----•-••--..........----•-••-----•---•-•--'-••--____•• •••-•-•--•-------•---------------•-••••---....--'•----••-•-•--•--------•-•-•------•-•-----•-'---- Location-Address or Lot No. Owner Address W Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.--_____--.-___-_-.-_--._. Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------•---•._.-..-.-.__ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity------------gallons Length................ Width..___-.-.-.-._-. Diameter_:-_--.---._-._ Depth---------------- xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------.-----------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. it. z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by-------------------------------------------------------------------------- Date------••---------•-•---•------------.... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...----_-__-.--_----.--- (1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ------------------------ ---•--------•--•------•-----------------••••-•--'--•---•••••......-••-•----......................................._..............-- 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x V ------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- W VNature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------------------------------••••------------•--•---•--•---•-------------------------------------•-•-------------•-----•----•---•-----------------•--•--•------------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 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