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HomeMy WebLinkAbout0414 OLD CRAIGVILLE ROAD - Health 414 Old Craigville Road Centerville A= 247-025 j No. 42101I3 ORA do V 0 10% 0 0 0 0 - Town of Barnstable Barnstable .�. Regulatory Services Department Q p RARN9TA13M NAMPublic Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520 0000 1971 7026 November 10, 2015 US Bank National Association % Secretary of HUD 4400 Will Rogers Pkwy STE 300 Okalahoma City, OK 73108 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system a Greywater System located at 414 Old Craigville Road, Centerville,MA was last inspected on Oct 24,2015 by Michael McDowell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Discharge or ponding of effluent to the surface of the ground. • Laundry room must be connected to existing septic system OR you may install a new septic system for the laundry waste water. You must submit permits to the Health Division once work is completed by the licensed plumber. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T E BOARD OF HEALTH Q:\Letters Septic Inspection Failuresor Further Eval\414 Old Craigvile Rd,(Graywater)Cent Nov2015 Town of Barnstable ELAMSMIS Regulatory Services Department '°Tea rN►'i" - Public Health Division 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Richard Scab,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 63-2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed Q'Rfr� Pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool u,, S ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or VA` clogged SAS or,cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any-portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER _l LA.AdrCoN✓I�� s-?P L S�sle Y'6v Vlnvht, N�►^' �PhL ft�J k y�, r AV^ W0 f= ov Repair deadline: -h4 Ilk r v.rJ t 5,1 pin C P- vi6f-[c 61 S C v-MP 2 WSEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc J Commonwealth of Massachusetts o��7' Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie Indiana 47303 Owner Owner's Name / information is Centerville �/ MA 02632 10-24-2015 required for every - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael McDowell use the return key. Name of Inspector The Building Inspector of America Company'Name 2 Brookside Circle Company Address Wilbraham MA 01095 City/Town State Zip Code 1-800-626-4408 156 Telephone Number License Number a B. Certification I certify that 1•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: ❑ Pas ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 40 10-24-2015 Inspector's Signature Michael McDowell MM/mil 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: N/A ❑ 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: N/A ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required-for every Centerville MA 02632 10-24-2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): N/A ❑ Observation of sewage,backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): - ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑.ND(Explain below): C) Further Evaluation is Required by the Board of Health: N/A ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if . the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Greywater System . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: N/A ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ N/A Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El N/A Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 L Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. N/A For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section.D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water.supply ❑ ❑ the system is within 200 feet of a tributary to.a surface drinking water supply ❑ ❑ ; the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with:310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Greywater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? . ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ -❑ N/A 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? ❑ ❑ N/A Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ® El Was on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? See separate report ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 88 gpd Detail: The last 2 years water usage totaled 64,000 gallons divided by 730 days equals 87.67 gallons per day(gpd). Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Greywater System . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ❑ NoN/A If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ® Other(describe): Single outlet pipe for washing machine and another for laundry tub. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) Approximate age of all components,date installed (if known)and source of information: Outlet pipes appear to be original with house, approximately 65 years old based on materials used and their condition. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewers(locate on site plan): Depth below grade: Unknown feet Material of construction: ❑ cast iron ❑40 PVC 11/z inch plastic pipe ® other(explain): Distance from private water supply well or suction line: 20' and 25' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Both building sewers exit rear foundation walls. They do not discharge to a septic tank or cesspool. Therefore they do not have%days flow available, which meets failure criteria. Septic Tank(locate on site plan): N/A Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Greywater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) N/A Distance from top of sludge to bottom of outlet tee or baffle 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 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.): Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): N/A Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Greywater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 414 Old Craigville Road Property Address P HUD/Ason s Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information required for ievery s Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): N/A 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(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* . Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): N/A If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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.): Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Greywater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I , Commonwealth of Massachusetts Greywater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Sketch is not to Scale =Inlet cover on septic tank XA=19'8" YA=1 TY B=Outlet cover on septic tank XB=27'1" YB=16'0" C=Distribution box XC=30'3" YC=18'8" O O A /� no 0 C Laundry B Tub Deck Y X Washing Machine Building Sewer own Water 414 Old Craigville Road mns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Greywater System . Title 5 Official Inspection Form R Subsurface S Sewage Disposal stem Form-Not for Voluntary Assessments P Y 414 Old Craigville Road Property Address HUD/ s 99 Indiana A on s Construction Inc. 1301 East Ri in Road Muncie Ind a a 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 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: 22 feet 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: 5-8-01 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: Blackwater system was installed into side of hill. Grade falls off greatly to right rear corner of property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Greywater System Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Washing machine and laundry tub do not discharge into blackwater system and are in failure. Recommend eliminating or tying in with blackwater system. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville V MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms "5/.aN 11 Z4/7( on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael McDowell use the return key. Name.of Inspector The Building Inspector of America Company Name 2 Brookside Circle Company Address Wilbraham MA 01095 City/Town State Zip Code 1-800-626-4408 156 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-24-2015 Inspector's Signature Michael McDowell MM/mjl 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. V� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys of 17 Commonwealth of Massachusetts Blackwater System . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 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: Note: HUD owned house. House is vacant and utilities were off at time of inspection. Septic system has not been receiving normal daily flows for an unknown length of time. There are grey water systems for washing machine and laundry tub. These two systems are in failure. Recommend eliminating or tying in with blackwater system. B) System Conditionally Passes: N/A ❑ 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 ekfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): N/A ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: N/A ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of.Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Y Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: N/A ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*.This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ N/A Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this.form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. N/A For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the.system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional-office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 S Commonwealth of Massachusetts Blackwater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is MA 02632 10-24-2015 required for every Centerville 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? El ® 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)Previous Title 5 report ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i L Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301.East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? See separate report ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 88 gpd 9 ( Y 9 (gpd)): Detail: The last 2 years water usage totaled 64,000 gallons divided by 730 days equals 87.67 gallons per day(gpd). Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: N/A 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: L11ins3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ' s Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown, HUD owned house Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system.by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 i }: Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Blackwater system was installed in 2001 as per board of health records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 inches feet Material of construction: ® cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: 23'6"feet Comments(on condition of joints, venting, evidence of leakage, etc.): Building Sewer exits middle of rear foundation wall. Septic Tank(locate on site plan): Depth below grade: 19 to 27 inches 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: 11'Lx5'Diameter,Approx. 1,500 gallons Sludge depth: 0 to 1 inch t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 } Commonwealth of Massachusetts Blackwater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road -- Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 10 inches Scum thickness 0 to 1 inch Distance from top of scum to top of outlet tee or baffle 3 inches Distance from bottom of scum to bottom of outlet tee or baffle 26 inches How were dimensions determined? With a tape measure&pole. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Fluid level was correct,equal with outlet invert. Septic tank appears sound and tees functional. Inlet cover on tank is 19 inches below grade and outlet cover is 27 inches below grade. Recommend installing risers on covers to within 6 inches of grade Pumping is recommended every 3 years. Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Blackwater System . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 414 Old Crai ville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every page. CityTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Fluid level was correct, equal with outlet invert(1). There is no evidence of solids carryover. Distribution box appears sound Top of distribution box is 29 inches below grade. Pump Chamber(locate on site plan): N/A Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I ..t Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road, Muncie Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 @ 500 gallonseach ❑ 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.): There is no evidence of hydraulic failure. However it should be noted the septic system has not been receiving normal daily flows for an unknown length of time. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool . Materials of construction indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 13 of 17 . r Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road - Property Address HUD/Ason's Construction Inc 1301 East Riggin Road Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA. 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the,boxes below: ® hand-sketch in the area below - El drawing attached separately Sketch is not to Scale =Inlet cover on septic tank XA=19'8" YA=1 TY B=Outlet cover on septic tank XB=27'1" YB=16'0" C=Distribution box XC=30'3" YC=18'8" O O O OO A C B Deck . Y X Building Sewer wn Water 414 Old Craigville Road t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Blackwater System W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 414 Old Crai ville Road Property Address HUD/Ason's Construction Inc. 1301 East Riggin Road, Muncie, Indiana 47303 Owner Owner's Name information is Centerville MA 02632 10-24-2015 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 22 feet Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevati on: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5-8-01Date ® 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: Septic system was installed into side of hill Grade falls off greatly to right rear corner of property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 J '3 Commonwealth of Massachusetts Blackwater System Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 414 Old Craigville Road Property Address HUD/Ason's Construction Inc 1301 East Riggin Road, Muncie Indiana 47303 Owner Owner's Name information is required for every Centerville MA 02632 10-24-2015 page. CitYrTo`^m State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Washing machine and laundry tub do not discharge into blackwater system and are in failure. Recommend eliminating or tying in with blackwater system. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENvmoN7ivmN7AL_A_FF_Ams a DEPARTMENT OF ENVIRONMENTAL PROTECTION o v�� C)W ©AS q4 TITLE 5 �p - 2 oo l -a V q OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �7 Property Address: T Old 944 0 60l � �,�� Owner's Name: Owner's Address: Date of Inspection: 6 O Name of Inspector:(please print) Company Name: �C Mailing Address: o Od Telephone Number: o 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>toSectio,,45340 of Title 5(310 CM 15.000). The system: Passes Conditionally passes Needs Further Evaluation by the Local Approving Authority Fails 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. �rfCC9*1^0 it 7� Iq S \\ Notes and Comment za(1 a �-O� Si h �✓ i h 6j q s�w►p w�-- >� L ****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 VOLUNT_aRY ASSESS mE_N TS SUBSURFACE SEWAGE DISP INSPECTION S � .SYS TEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Q�C' Owner: V 7 /� oZ 6 o Date of Inspection: 6 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst asses: 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,N-D)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 enfiltration 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. NI D explain: Observation of sewage backup or break out or high static water level in the dstnbution 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 STD 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: Title G incnurtinn T:'n r,,.,���si�nnn 2 I Page 3 of 11 ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'YIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: kit 601 Owner 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 system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CNIR 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 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 welt_ is_free froti_i pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 triggered.A co PPm,provided that no other failure criteria are tri gb copy of the analysis must be attached to this form 3. Other: i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME-NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address 01C '�d �S ✓ Owner: �� r Date of Inspection: a6 $ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓_ B�up of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or caged SAS or cesspool /Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or c pool 4-1 L�depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o-O-- es pumped 4- A�ky'portion of the SAS,cesspool or privy is below high ground water elevation. _C/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface w r supply. �/A!-portion of a cesspool or privy is within a Zone 1 of a public well. (, A on 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 forin.] (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 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 e system is within 400 feet of a surface drinking water supply 4th ee 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—I VPA)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 sic ifcant 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 CiR 15.304.The system owner should contact the appropriate regional office of the Department. Titl< 1 incnontinn p All;1_)nnn 4 , Page 5ofil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY. SESS.Nf p TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / ©Q Owner Date of Inspection: 6 D Check if the following have been done.You mast indicate"yes"or"no"as to each of the following: Yes � o Pumping information was provided by the owner,occupant,or Board of Health "-Were ere any of the system components pumped out in the previous two weeks ? t/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? v Were as built plans of the system obtained and examined? not / P Y {If they were not available note as?V/A) Was the facility or dwelling inspected for signs of sewage back up? v _ 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 maintenance of subsurface sewage disposal systems? proper The size and location of the Soil.Absorption System(SAS)on the site has been determined-based on: Yes no xisting 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 C1M2 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: q,Al Owner: .41 Date of Inspection: 01 OW CONDITIONS RESIDENTIAL Number of bedrooms(design):gn): Number of bedrooms(actual): cZ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: O Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system yes or no):,4Vif yes separate inspection required] Laundry system inspected(yes r no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):. Last date of occupancy: C OIVLMERCIAL/I1V-DUSTRL4L Type of establishment: Design flow(based on 310 CvIR 15.203): gpd Basis of design flow(seats/persons/sgf,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): Pumping Records GENERAL INFORMATION i Source of information: �✓ S �..� �yT C4 '7�� Was system pumped as part of the inspection:At®r : If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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 an _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 co ent ,date installed(if known)and so ce f mfQ�tion: /9 - �f-- Were sewage odors detected when arriving at the site(yes or no):/l/id T;tiP G �ncnortinn Tfnrm (./1 c/�nnn . 6 i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNT_A.RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) G� Depth below grade: Materials of construction:—cast iron `fQ 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: pZ� /� Material of construction: ncrete metal fiberglass_�7olyethylene —other(explain) — ��N If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 01 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / " Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom �otltlet tee or bile: 7 !� How were dimensions determined: 0//P �{4;S < Comments(on pumping recommendations,inlet and outlet t or baffle condition,structural integrity,liquid levels as re ted to outlet invert, evidenc of leakage,etc.): / vt o' e c' �l GREASE TRAP:&/_(Iocate 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 i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ILf Old C/orli,�v11/e �ej Owner: J r Date of Inspection: TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal_fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/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: (if present must be opleeneeid)(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 ' to or out of box„et��/ o � PUMP CHAMBER:klocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber,condition ofpurnps 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- IZ� Owner: L Im 7 , -T,0� 7�4- Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type oc� leaching pits, number: s�o / 0/� leaching chambers,number: (� �'/ C� 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_): 0 ", ��C/vl �/�O H 4 �t e i !Q`�J /I /" CESSPOOLS:�esspool 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 ofhydraulic failure,level ofponding,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 ofponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSAJEN, S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART C SYSTEM INFORMATION(continued) Property Address: L Ile- Owner: , r iP/ 41— Date of Inspection: a�� 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. QCcu e V-� 10 L - - i— C_ --"� Cam- � � :� —i•r 1 i _ Page 11 of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION/� (continued) Property Address: �YlL old 1.'G'15 l!/e x� f Owner: 0? Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells I�Q ' Estimated depth to ground water feet tm fir Please indicate (check)all methods used to determine the high ground water elevation: Ob ' ed from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole 150 t f SAS) Checked with local Board of Health-explain: f/%? � Checked with local excavators,installers-(attach documentation) IOf Accessed USGS database-explain: You must describe how you e tablished the high ground water elevation: , IL r ' -r:*�o� r��•.o�rr,,., Fnrm�n si�nnn 11 l I No. � Fee r. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippitcatton for Mtzpool *p5tem Congtruction Vermtt Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 'y/ Owner's Name,Add sss Tel No. l o t /9 A `1 j/ 1/-w4o k.e o-h C ' Assessor's Map/Parcel Installer's Name,AddAs&We CO Designer's Name,Address and Tel.No. S50 Main Street W. Yarmouth, MA 02673 Type of Building: J? /►'►%� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil N ture Re 'rs or Alter tions(Answer when a plical/le) r J d �4 �� • off• c — oo 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 Enviro ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board alth. / Signed Date 41, Application Approved b - Date 24 Application Disapproved for the following reasons Permit No. Date Issued No. 2dP1_.7V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Mizpogal 6pttem Cow6truction Permit Application for a Permit to Construct( )Repair( ,/upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. �/1 A' v' Owner's N Add ss and Tel.No. A-f l9 A �' / !1 *11,4 Pon ame, ?Mpi;+ Assessor's Map/Parcel �!�/� .... ��� Installer's Name,Address,AWWCANCO Designer's Name,Address and Tel.No. S50 Main Street W. Yarmouth, MA 0267 Type of Building: Dwelling No.of Bedrooms c) Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title a Size of Septic Tank Type of S.A.S. Description of Soil N ture Re irs or Alterations(Answer when applicable) Z nJ A D O A T 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 Enviro ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo\ardp� alth. Signed \/ Date Application Approved b Date L Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- '- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On- ite Sewage Disposal System Constructed( )Repaired( L4<'graded( ) Abandoned( at Q� �' � 2�, , 7l) S has been constructed in accordance with the provisions of Title 5 Ad the for Disposal System Construction Permit N ,I dated_w��� cstS Installer Designer The issuance of this pe t h - all not be construed as a guarantee that the syste ill fu ti designe Date Y / d/t l Inspector --------------------------------------- No. rLr•, tofd1- Z Fee F THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mooar *p!5tem Cow5tructiou Permit }I Permission is hereby �t d to Construc ( ) epair( ade( ) Bandon( ) System located at �� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t ,permit. j Date: Approved �� ��: � c�l�/??�,•n i r 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL ^ WORKS CONSTRUCTION PERMIT W( ITHOU'I' DESIGNED PLANS) 1, �� 64-utwoq� , hereby certify that the application for disposal works construction permit signed by me dated �l `y , concerning the a property located at q(q Cra`���`� �dC . gy meets all of the following criteria: /This failed system is connected to a residential dwelling only. There are no commercial or business uses.,associated with the dwelling. /he soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • here are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed ( here are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when pplicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevatiod3•� +the MAX. High G.W.Adjustment.a• t = 17�o DIFFERENCE BETWEEN A and B SIGNED : 'J DATE: [Please Sketch proposed plan of system on bac . NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert z '\ �� � � �� as o ( �� �_ O l b c�� Sd L �, TOWN OF BARNSTABLE LOCATION 71Y O06 Wa- I ,O SEWAGE # Zoo!-'IqO VILLAGE C'�'n-�/G'�I�CLC t ASSESSOR'S MAP & LOT Zul-yZS— INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �/ C�t (size) Ga NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 41-1 1 Zoo / COMPLIANCE DATE: 'T-Y'0 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 �1 C K ' 1 �- 30 z�' 0 7/29/2021 ShowAsbuilt(1700x2800) liuv.l- 4SI I Oa l i� 0� hn Y 5C IRS 611J11M! T�N� 13' ' Ct9 B�x i L Q r !y A TOWN OF BARNSTABLE v LOCATION7'y4WLj94I!.✓4t-a- 16*10 SEWAGE# ZOOI ZyO VILLAGE C'EAflegil Q ASSESSOR'S MAP&LOT Zul'tUZ.S- INSTALLER'S NAME&PHONE NO. A1B C'IsAl" SEPTIC TANK CAPACITY /31� LEACHING FACIIrrY:(type)A-SZ16GafL'Ns9!^1�'S (aim) ZS'ntyeZ' NO.OF BEDROOMS ,Z BUILDER OR OWNER i»l-J7— PERMI•rDATE: q-o-7,00l 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 https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=247025&sq=1 1/1 TOWN OF BARNSTABLE LOCAT16N.4/ A�20 SEWAGE # 00 qO I`ILLAGE_L� 1 ASSESSOR'S.MAP & LOT 240 07-s- INSTALLER'S NAME&PHONE NO. e SEPTIC TANK CAPACITY /T_�m 61W LEACHING FACILITY: (type) ot (size) z 13`)(2- LZ�77- NO. OF BEDROOMS ,/,d q�Ajp BUILDER OR OWNER PERMITDATE.: y_15 -Zoo 1 --COMPLIANCE DATE: Separation Distance Between the: ;-Kaximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Waiter Supply Well and Leaching Facility (If any wells exist . .. on site or within 200 feet.of aching facility) 2- Feet Edge-of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. Furnished by AgoP-4 3b S i zo7 y Clow VA IIcS4 v 5 I.S x pPeai c�ob�� 15 T-vll c , - ev"h '{RiA�t.►aS t1wp�� 36'� �� ` W*`1 QesT, S3 Co. `go1C + - t Lll'-1 p\a C,0-0%9 V L\\r_ Cz i `J ! i �vo�sea LAVA O�d1 C � ��C Raa�► r �, �Ia G�o? RI i R. 72ocl 7v3d9 qJ�- Rar-(ll�r utSfry Anna �,Ymv✓✓ .. .. - p v �S 9 91 \YSl msu(ah �\ r)° -------------------- 1 ' Iv �� 1'u11�71'a�D�W1 CbYttdllY � - \J4LY .' �' � i CAOSIJ- Q� ! ocr s , . �� � 1 "1,�►try . 16 3 1 1 "