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Home My WebLink About0035 NAUSET LANE - Health 35 NAUSET LANE, CENTERVILI E A= 170 018.009 UPC 12543 r �� Nd '`bsrcoc � HASTINGS,MN TOWN OF BARNSTABLE LOC LION SEWAGE # VRJ'4,AGE_ C �N��A ASSESSOR'S MAP &`LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACM LEACHING FACium (type) O e OS+ l2 14— (size) UUU NO.OF BEDROOMS BUELDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 — (�\� I beck A 0 � IAc 10 t 4a� Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: I I only the tab key to move your Michael Kellett vv�� cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name 4:1 P.O. Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.Th'e inspp-Oction was performed based on my training and experience in the proper function and maintenance-bf on s to sewage disposal systems. I am a DEP approved system inspector pursuant':;to Section 15.340f Title 5 (310 CMR 15.000).The system: -, ® Passes ❑ Conditionally Passes ❑ Falls , n ❑ Needs Further Evaluation by the Local Approving Authority ° i V"► 05/11/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required forCenterville MA 02632 05/10/10 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: ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M SVey'�t 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Flame information is required for Centerville MA 02632 05/10/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 220 p gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 08/08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (f known) and source of information: 25 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 35 Nauset Lane ' M Property Address Donna Dagastino Owner Owner's Name information is required fw Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.0feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 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: 1000gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 3" i Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overFlow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The system has a VxV precast pit surrounded by a foot of stone.The pit was dry with a stain line 30" below the inlet invert. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required tar Centerville MA 02632 05/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 35 Nauset Lane Property Address Donna Da astino Owner Owner's Name information is Centerville MA 02632 05/10/10 required for State Zip Code Date of inspection every page. Cityrrown D. System Information (corn.) 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. l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 35 Nauset Lane Property Address Donna Dagastino Owner Owner's Name information is required for Centerville MA 02632 05/10/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �f Property Address: 3S,463u La AA _ ` /� t-21 O�� -�y Owner's Name: qy,t .,vgga3�'iM, Owner's Address:_ GC/ ' Sv _ td Date of Inspection: 'p 6 / Name of Inspector: ( lease print) M-?1-kse( ellllle ff Company Name: e �i ( Y rnsp<Ctt,0 K.S Mailing Address:_ D gqz f ,e"AX�g od 6?f/ Telephone Number: Sy8 :3B'S -Zko—,P 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: a Passes . .� Conditionally Passes u, Needs Further Evaluation by the Local Approving Authority' Fails t a Inspector's Signature:._%y� G� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health'or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1.0 900 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 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 3S Q vS,e� L•a ✓i Owner: Date of Inspection: 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 Hea th,.will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If' determined"please explain. The septic tank is metal and over 20 years old*or the septic tank ether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failur ' imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approv y the Board of Health. *A metal septic tank will pass inspection if it is structurally und,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail e. ND explain: Observation of sewage backup or ak out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,s ed or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pipe(s)ame.replaced obstruction is.removed distribution box is leveled or replaced ND explain: The syste required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspectio if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPEC T ION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGE AGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L-PAL---( Owner: p 3 C Date of Inspection: 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 stem is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.3 (1)(b) that the system is not functioning in a manner which will protect public health,safety and t 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 s marsh 2. System will fail unless the Board of Health(and Public W er Supplier;if any)determines that the system is functioning in a manner that protects the public h ith,safety and environment: _ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. _ The system has a septic tank and SAS the SAS is within a Zone I of a public water supply. — The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Me od used to determine distance "This system passes if the ell water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile or Iis compounds indicates that the well is free from pollution from that facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are goered.A copy of the analysis must be attached to this form. 3. Othe . 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A- CERTIFICATION(continued) Property Address: 3 — IVOW5 f 4A--O( Owner:_80.5C 3 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No it 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 k Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool A Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow { Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 4C 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. C 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_compounsis 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 S ppm,provided that no other::f"ure criteria are triggered.A copy of the analysis must be attached to.this form.] IVO (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 Systems: To be considered a large system the system must serve.a facility with a d 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 'eria above) yes no the system is within 400 feet of a surfac g water supply — the system is within 200 feet of butary to a surface drinking water supply _ — the system is located in a trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public w r supply well If you have answered"ye ' to any question in Section E the system is considered a significant threat,or answered "yes"in Section D abo the large system has failed.The owner or operator of any large system considered a, significant threat and Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste wner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J�N m ✓%( V- Owner: A6Ag i's e_ Date of Inspection: 10 6 y 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? 0( _ 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? 1 _ 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 J� _ 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 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C AA'' SYSTEM INFORMATION Property Address: -Na-se, ✓ -ay Owner S e Go. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_. Number of bedrooms(actual): a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): owl Number of current residents:0 Does residence have a garbage grinder(yes or no): AM Is laundry on a separate sewage system(yes or no):A10, [if yes separate inspection required] Laundry system inspected(yes or no):LVo Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:!i O,: COMMERCIAL/INDUSTRIAL Type of establishment: ` Design flow(based on 310 CMR 15. am Basis of design flow(seats/perso sgft;etc.): Grease tra/pancy/use: es or Industrial g present(yes or no):— Non-sanita hanged to the Title 5 system(yes or no):_ Water met if available: Last date oy/use: OTHER( GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons— How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x 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: Were sewage odors detected when arriving at the site(yes or no): /U d 6 Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: i Owner: / �OSe S GG1 Date of Inspection: 2st BUILDING SEWER(locate on site plan) , Depth below grade: a L/ Materials of construction:_cast iron ,a 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: X (locate on site plan) Depth below grade: 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: l 060 Sludge depth: S:" o N Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_cLo _ N Distance from top of scum to top of outlet tee or baffle: 7 r Distance from bottom of scum to bottom of outlet tee o baffle: How were dimensions determined: 11-'E^f W't Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as relate to outlet invert,evidence of leakage,etc.):Ir�' L 1 `t'r� lc. �V4S bOt1 aKt�` }► 1 �CtS t ek"s Ii v�`(! GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fi Mass-polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to to/omof baffle: Distance from bottom of scum tet tee or baffle: Date of last pumping: Comments(on pumping reco endations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert idence of leakage,etc.): 7 Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) /`� Property Address: 35. at-?52TT1 "vu& Owner: a Date of Inspection: '1 al ID b TIGHT or HOLDING TANK: (tank must be pumped at time of impection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: •gall s Design Flow: ons/day Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOX:_A (if present must be opened)(locate on site plan) Depth of liquid Ievel above outlet invert: e1/et4 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leaka a into or out of box,etc.): boK wc►s le�c� �- � L0 t4t. ,tip 6Lc,� ar� fX11 i PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or Alarms in working order( or no): Comments(note cond' ' n of pump chamber,condition of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: riausweA l..gv..e Owner: 1 y 1Obt-V6%Xk Date of Inspection: 'V 31 10b SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS.not located explain why: Type k leaching pits,number:J 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.): S 4'-) (�VVl a Ct u ,it,. W& UP, . CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet ' m Depth of solids layer: Depth of scum layer: Dimensions of cesspo Materials of cons tion: Indication of gro dwater inflow(yes or no): Comments(not condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: (locate on site pl Materials of construction• Dimensions: Depth of solids: Comments(note ndition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f VAwSQ,+ "._k Owner: M05e s - Date of Inspection: 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. c r 1� V' r i b Page I I of I I OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ?� � ) SYSTEM INFORMATION(continued) Property Address:�L'l`� 5 e+ �A"A Owner: Date of Inspection: ? � � OG SITE EXAM Slope A(4 Surface water%JIO Check cellar Q-5 Shallow wells VW Estimated depth to ground water—Q0 feet 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 Iocal 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 tion:elev yS GAS rn�e�4 -� Vnnuo c,�v. e �Q✓ �a e� o�S�/l �y 11 Commonwealth of Massach usetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 John Grad D.E.P. Title V Septic Inspector F P.O. Box 2119 Teaticket, MA 02536 (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI 9 f Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO Mtn dd� PART A CERTIFICATION 01 a Property Address: 35 NAUSET LANE CENTERVILLE MAP 110 PAR 018-009 Address of Owner: Date of Inspection: 11l17l98 (if different) lq Name of Inspector: JOHN GRACI MR.WAYNE BAKER;363 B IN Pl�� ITERVILL 8 hft I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: E Z 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title V code 310 CMR 16.303.My findings are of how the system is _ Condit' all Passes performing at the time of the inspection.My Inspection does _ Needs ur er Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe Falls septic system and any of its components useful life. Inspector's Signature: /f Data: 11121/98 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 019-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11r17199 _ Sewaae backup or,hreakout or high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis 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 in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or pondiny of effluent to the Surface of life ground or surface waters due to an ovtirloadtld or Clogged cesspool. ~ SAS is in hydraulic failure. (revised 04117B7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11117198 D] SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety 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 II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revlaed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11117198 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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 part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)) (revleed 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:'11117198 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): Na Sump Pump(yes or no): No Last date of occupancy: Na COMMERCIAL/INDUSTRIAL: Type of establishment: Na Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: Ne Last date of occupancy: n1a OTHER:,(Describe) rde Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: r9a TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 1984 Sewage odors detected when arriving at the site:(yes or no) No i (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11117/98 SEPTIC TANK: X (locate on site plan) Depth below grade: 16' Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age ria . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L6'6-HB"r'W41-10" Sludge depth:2' Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness:U Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: MEASURED Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: Na Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumping,,(. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na BUILDING SEWER: (Locate on site plan) Depth below grade: 22" Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction IinerOWN Diameter. nla Cvaimments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11111117198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: We Capacity: rda gallons Design flow: rda allons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nra Comments: , (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) We (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 Owner: MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE Date of Inspection:11117199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers, number:rva leaching galleries, number: ria leaching trenches, number,length: rda leaching fields,number,dimensions:rda overflow cesspool, number:nIa Alternate system: rda Name of Technology._nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) THE LEACH PR IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAD 4'OF WATER IN IT.PIT HAD 2'OF LEACHING LEFT ATTHE TIME OF THE INSPECTION. CESSPOOLS:_ (locate on site plan) Number and configuration: nra Depth-top of liquid to inlet invert: rda Depth of solids layer: nla Depth of scum layer: Na Dimensions of cesspool: r9a Materials of construction: rVa Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) rVa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Ne Dimensions: rya Depth of solids: rva Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n!a (revlaed=7)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE 11/17198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) Pin 6 D Rgb C AC 40 13 (revised0A11719T) Page 9 of 10 JaQ R. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 35 NAUSET LANE CENTERVILLE MAP 170 PAR 018-009 MR.WAYNE BAKER;363 BUCKSKIN PATH CENTERVILLE 111/7198 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS aevised04nT197) page 10 of 10 Nob-:.L-69... . ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................. IJJ.n..........OF.................4Lr..61 A� Oe_ ..................... Apli iration for Bispoii al Works Tomitrurtion 11amit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: ................ .�......... 1 n�- - 3 -•-•--.... ` Location-Address Q or Lot No. .. 0.M s---.......K......... . a....... ...............--�1�'....---... . ........... _ nr11.�..... Owner Address ._ _ a. `1. �._...... �-?..........-•....... .......... .•--•- ..r��.r1 S \ off ' Installer AddressPQ U Type of Building 3 Size Lot-�__ss�� ,.a'�a-'__..Sq. feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder QJC� A4 Other.—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P.4 Other fixtures ._...---•-----------------•----• - W Design Flow._..__.....�k.Q.......................gallons per person per day. Total daily flow............ ...................gallons. WSeptic Tank—Liquid capacityffi. -_-•_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. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.__.___ ' ........... Date........ .......... ,.� Test Pit No: 1................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..................... Pd •-••---•....... ...................--•---- ----- ...... . .._..........-........---•--•---------------------. --•--•. O Description of Soil........ .— ..- ............ 5 � x ---------------------- a-... . .........maa-&A........ ------•----- ......... e.......ja-A►el...vj---- 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 iITLL 5 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 t ealth. Signed---- .................................V ............. ...................... •l4.. "-------- Date Application Approved BY _--- ..! ,� ----------------- Date Application Disapproved for the following reasons---------------••-------------------------------....---------••-----------------•-----------••------------------- .............................•-------••--•---•-••---••--------------•--•------------------••-----------....•--------•-••--•-----•-•------------------------•••--••-------•-------•--------------••-•----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH - ............ ......OF............ � . .............. .Z° ppliration for Uh4paii tl Works Tonstrurtiun jhrmit Application is hereby made for a Permit to Construct ( t-15 or Repair ( ) an Individual Sewage Disposal System at .... ..`... --•-•-.....•,�� Location-Address ••or LotIs No. Owner. Address Installer Address r� Q Type of Building Size Lot__1.?:�...Sq. feet Dwelling—No. of Bedrooms.....................3 ....................... Attic ( ) Garbage Grinder (4, o Other—T e of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) QOther fixtures -----------•---------------------------•--••-----------------•----------•------------------•-----------•----._•--••- ------ Design Flow............\.�10.......................gallons per person per day. Total daily flow............ .......gallons. WSeptic Tank—Liquid capacityl'�.� _.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 ( ) aPercolation Test Results Performed by........_-CJG!._C-k:':'......._ _., '`�.......... Date....._._. _.�?.".��......__. a Test Pit No. 1................minutes per inch Depth of Test Pit................_... Depth to ground water........................ f3L, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 -----------=3. ---•-�?- ................. ..... ......................... ......._ ...... 1C n.�O Description of Soil-------- ' . _ �_rn....._ ....��V - r � '. .. c� ._ a.e ...... n. UW ----•---•--••--...-----•----------=•-------------------------••-••••-------------------..,..-------•------•-----•---••-----•----•-••----------•-•-----------••••••-•••--•-......--------•............... 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 TITI—E 5 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 theboard of alth. ►1 Signed.. ......--•--- - -.• --•---_...__ -Lt -= �"........ ,+ ate Application Approved By--- .•.• - .... " ' - :.................. eP "` . --._....------ Date Application Disapproved for the following reasons:------........................................... ------•-------.............................................. .................•---................-----•--•---------------....----------------•-----------------•---...-----•------------•----•------------------...--------------------------------------••--•---•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a ......... 7.�.�--Jn.........OF............. .i ............................................... Turrtifiratr of Toutplittnrr THIS IS TO CERTIFY, Tl t the Individual Sewage Disposal System constructed ( L4 or Repaired ( ) by........... �'.. �r�....._•--••--• • t s.--•....................•---•-------•-•-----.......-•-•-----•---........-•-•---•--•-----------..........----••----•---....._ Installe \ at -- �--•-------3--U- ----0._( .....k. ___ A --- --_�-�ln e. �n_�t-._�1�.t�V�- .. has been installed in accordance with the provisions of TITLE 5 of.The State Sanitary Code as described in the "'► application for Disposal Works Construction Permit No--- ` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE. L -----•------...._. Inspector.... j"'1 • --1-1111------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o. � —............0F................� '? N ' E:. .. ..... ..... ---•---•--...._.. FE Dispoal Vorhfi Tnnotrurtilan rrntit Permission is hereby granted--------. .............. - ..----------•------------------•------•-----.....--•---......-•----••---•--- to Construct (L,.--�or Repair ( ) an Individual Sewage Dis osal System r• at No............ -- .............:�>-4—` ..._.-_ � �- � � -- as shown on the application for Disposal Works Construction Permit �--=�(l�-' Sttrr eet io ^ No..................... Dated------ .............................. ._ -:.............•---- 0 .----............................. Boar ealth DATE---------------- '.......... ... - FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 'S%W GLC- FAMILY - :5 BG-b9-COLO M ,.�25.5 9� •�� No GAtZgAGF= (�czIJ.�Dt✓tz:" _ _ •. o `� — DAILy FLOW z 110 x 3 - 3306.Pt? o •o j .5EPT1G TASK = 330x15c>% r-49SG.P. N u51=- 1000 GAL. 3C hXP / Dt5po5AL P►T v5E t G00 S%DEWALL AP-Sh, = 150 S.t= yC 15O 5.F X 2 •5 - 75 G,F?U F30TTOM AR.EA-r �1. .r+•F, FouyDATw.I -TOT A>-. D E 516W = 4 88 TvTAL- DA t L.N,( FL-C>W - 330 G Pv M I U PE2COLATIDI.1 RATE - VAIN ZMIN oczL�55 - " q� - C' All �Ar 30 J\k OF A IN 4 TER JO t Ju �`�M� /. '•,T , YOB. /• O . t Tt�5T To P FND=too. NoL� 77 ^ too 99.6 1000 wv. Sub Sol, DIST. G D AL. 9 7.7 i z 9G.E INS. t3�X 974o SFv7�G s I GAI,. 'JG.GQ 6RAVeL LEAGLI . .. I .._ ' Mt`—DIUM " SAND WA 5u6D i j F�NC GER.TIti=i cm-D PLnT P1.-AtW ?� sAN D. � . LOL4'TIOtiI G�TyTERvIL_tE I N o SCALE 8e SCALE [IN=40 T I W ET SAN D . _.-.. ... __ z 1 ERTIFY -T H AT '1'1N� FovKDAT%o%L : µO>" (N pl-At�l REFE�EM C GE I µERCO►.1 COMPL`(5 WITO-THE s101rL1Wr— L-OT` 3O AIJD 6STeACK 2�Rv►R-EMEN`I"S oFTNE- 1 �dwN aF= �ARN�h13�E ANC 1s IyoT . PL LOGp.TED •�r�11T1�1t.1 T1-lE t^LOdD PLAl1�J ROGER J, b pa2o�tiY E• �AGKuK D AT Q ' I:) GrL..r ►J U�!, 5� I `� I ' REG l 5'T 67-E-D'LA1.1 D S u PN C-yc'ZS TM5 PL/\t\l 15 NOT AN os-1-Ee.vILLC- IW,5TIZuM6NT 15u2V�`( THE OFFjF--r 6uout: > :! f•.(oT C'�� V�EDTb (7ETC-_{ZMIN� l..o�' 1.-I�E.�j Ii4PPL.IGA► •IT JA�MES 'K. SM ►TN 'i Lea AT '1 N SE.WAG PERMIT 0• 6,64f aQ s L h a' VI! LAG E " �70 0/5' ao� I'NSTA LLER'S NAME i AD..D.RESS ()C-,m e/&o lflz o s .T�tl c ZX/2•� BUILDER OR OWNER' v S T i DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ' OL4 �� rr