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HomeMy WebLinkAbout0067 OLD FARM ROAD - Health 67 OLD FARM RD. CENTERVILLE A =231 008 nn i 6PC 12534 No.2�183LOR � s MAiTINYi�YN 1 i 4 t i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti caner Owner's Name Formation is Centerville Ma 02632 6-9-15 quired for every State Zip Code Date of Inspection age. City(Town 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 Al l, 7� O G� 3d ❑ LAW 3 C. 0 0 A,, t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 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 (WITHOUT DESIGNED PLANS) I, Joseph P.Macomber J r . , hereby certify that the application for disposal works construction permit signed by me dated 4/15/9 9 concerning the property located at 67 Old Farm Road Centerville ,Mass . meets all of the following criteria: /The failed system is connected to a residential dwellingonly. There are no commercial y o erciai or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes.per inch. There 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 There 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 applicable] 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) 7 B) G.W. Elevation A--5- +the MAX. High G.W. Adjustment. 7,/ _ S-Z DIFFERENCE BETWEEN A and B SIGNED : -ff�e z � DATE: r4 (Sketc sed plan of system on back). q:health folder:cent 1 1-1500 gallon Q Tank I � 1-Distribution 0 12-500 gallon box. / Chambers . C <<L Commonwealth of Massachusetts �`( a3/ _��g Title 5 Official Inspection Form Rj Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name / information is required for every Centerville ✓ Ma 02632 6-9-15 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 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City(rown State Zip Code (508)477-0653 S113747 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 6-9-15 lnsvxs Si nature 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.. m �5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G H . 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 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. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 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.): ❑ 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 obstructedpipe(s). The Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 4 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system'owner should contact the appropriate regional office of the Department. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (9P ))� Detail: 2013-(126gpd) 2014-(378gpd) Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank (locate on site plan): Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M , 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order, tees present with no sign of back- up.Liquid level equal with outlet invert. Tank is not in need of pumping at this time but should be pumped every 2 years for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. Cityrrown 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.): At time of inspection d-box appears to be in working order with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500gallon chambers ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Chambers were dry with a stain line 1' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. Cityrrown 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 Ai, - 7_( at-Ili 62' Its' O O ii3y NZ C-L• 3d ❑ GS 44' S C I � O A,4 t5ins.-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. Cityrrown 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: No Gw 15' 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: permit app dated 4-15-99 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: Permit app on file at BOH. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 67 Old Farm Road Property Address Jeff Ruberti Owner Owner's Name information is required for every Centerville Ma 02632 6-9-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 y z tt CIA 'Tl`1SPE �'iON FORA' —NOT IFOR•?VOLUNTAR'Y-.ASSESSMENTS SI 5URFACE'SEW- AGE DISPOSAL SYSTEM-.INSPEC ION:FORM , PART C SYSTEM INF-ORMAT'I.ON(continued)` T operty Addresso6 7 U 2r1 2n.�22U.G�.QD l�n §' own eaine loha oa 1 Date of Inspection: 7/9 5/Q ! •'. SKETCH OF SEWAGEMISPOSA•L S1kSTEM Provide a sketch of the sewage dispg a ' f, bent arks.Locate all wells within 100 feet.Locate where public water supply e�tgrs.the building. 10 ' I 1, 1 V . SO�SMPQ Np PSSES DATE_ 7/15/04 PROPERTY ADDRESS:_67_0.ed Ta.zm Road - Centeay.i-"e, Na., CQ� 02632 �. 0 On the above date, the septic system at the above address was Inspected. This system consists of the following: 1. 1-1500 ga.eeon ze/24.ic tank. 2. 1-Dizta.igut.ion Sox. 3.,2-500 ga.2.eon eeach.ing chamge'az. Based on Inspection, I certify the following conditions: 7h.iz .i s a 714ie T.ive Septic Syzt em (9 5 code) The zept-ic 3yztem .iz Raopea woak.ing oadea at the paehent time. The ieach.iny chamgea,6 weae day at time o� .inz/zect.ion. SIGNATURE:jL - ---- Name:_ Bauce_N 'ca ei i stea - 0 C � crn Company: .Tn�h$__fir.,_�, Inc. 'P r 0 T ;p m Address:- P- -Q--Bnx-6L----------- N No rn �W C=) r nte--rviiie, MA 02632 0066 m 'Phone:_--1 Q$1 7 7 5--3�3$--------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY CJOS.EPOH P. MACOMBER & SON, INC. Tanks=Cesspools-Leachfiel.ds Pumped & Installed Town Sewer Connectlons x 66 Centerville, MA 02632-0066 775-3338 775-6412 • i r � i- o0% COMMONWEALTH OF MASSACHUSETTS £XECUTFVE OFFICE OF ENVIR4NM` NTAL AFFAIRS r DEPARTMENT OF1NV1 t"MENTAL PAMOTION d y ' a3),00W -� - TITLE 5 OFFICIAL INSPECTION FORM—.Np.TFOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address:6..77 O-ed Fa a m /fin i-i rl Cetnezy.CQ-ee .Na 02632. Owner's Name: a.irze 7ohnzon Owner's Address: 6 am e Date of Inspection: 7115104 Name of Inspector: (please prinq��u�P_ 9a ca_e4:,6,t e.2 Company Name; 7_ �_.MacomRe�t, 9-SAn Mailing.Address: a en e2U:L 2, 4.6,Z-0 2 6 3 2 Telephone Number: 5 0.8-,7 7 :3 3 3 8 CERTIFICATION STATEMENT 1 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 Oioper function and maintenance of on Bite sewage disposal systems.I am a DEP approved system inspector pursuant to=Section 15:340.of'T,itle 5(310 CMR45:000). The system: XPasses Conditionally Passes Needs Further Evaluation,by the Local Approving Authority Fails Inspector's Signature: Dater 31 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.shargd system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.slialTsubmit 1l e: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. 'rWo c r,,.,.P,.+ce%„ Firm 6/15/2000 page 1 , i Page 2 ipf 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:6 7 0_0d ;rg zm. /toad Cente2v� ��e J'la Owner: Uaine 70hnzon Date of Inspection: 7/1 5/0 4 Inspection Summary: Check. A;B;C;D W or.E/ALAYS{complete4ll of Section,D A. System Passes: M 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. VI D The septic tank is metal and over 20 years old*or the,septic tank(whether metal or not).is-structurally unsound,exhibits substantial.infiltration or exfiltration.or tank failure:is:,imminent: System.will pass inspection if the existing tank is replaced with a complying septic tank,as.approved by.the'Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection-if(with approval of Board of Health): broken.pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: DO 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 �I ND explain: 2 e Page,3 of 11, OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI.ON.FORM PART A CERTIFICATION(continued) Property Address: 67 Oed Ta2m /toad Cen.�e2v-i.�.�e Owner:. (E$aine lohnzoit Date of Inspection: 7115104 C. Further Evaluation-is Required by the Board of Health: o Conditions.exist which require further..evaluation.by.the Board,ofHealth:in order to:.determine ifthe 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 wwfl protect public health,safety and_the,.erivironment: no Cesspool or privy is within 50 feet of asurface water 0 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 mariner that protects the public health,safety and environment: nO The system has a septic taitk and soil absorption system(SAS).and the SAS is within 100 feet.of a surface water supply or tributary to a.surface water supply. n© 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. no The system has a septic tank and SAS and the-SAS is less than 100 feet.but 50 feet or;rtiore fiottf a private water supply well". Method used to determine distance "*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5.ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be attached to this'form. 3. Other: i Page 4 of 11 OFFICIAL,INSPECTION FORM-NOT°FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:6 7 O.Pd Fa2m 12oad Centenv.teie Ma Owner: f a.ine 7ohnzoa Date of Inspection: 7115104 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 _e" 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.. Any portion of a cesspool or privy is within a Zone 1 of a:.public well. / Any portion of a cesspool or privy is within.50 feet of a private water supply well. / Any portion of a cesspool or privy is less than 100 feet but greater.than 50 feet from a private water supply well with no acceptable water quality analysis...[This:system..passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds indicates that the well is free from pollution;:from::that.facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are-triggered.A copy of the analysis must be attached.to this form.] (Yes/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• A. 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 l the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located'in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant.threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 i Page 5 df 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM PART B CHECKLIST Property Address: 67 Oed 7alim Road Cente2v.i.Qie Na Owner•C-eaine o n son Date of Inspection: 7/15/U4 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? r/ Have large volumes of water been introduced to the system recently or as part of th' inspection? Were as built plans ofthe system'obtained and examined?(If they were not available note as N/A) — Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material•of construction,dimensions,depth of liquid,depth of sludge and.depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS).on the site has been determined based on: Yes no I/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)J 5 Page 6 of 11 OFFICIAL INSPECTION::FORM`-NOT FOR VOLUNTARY ASSESSMENTS SUBSMACE SEWAGE OISP.-.OSAL SYSTEM,-INSPECTION FORM � PART C SYSTEM INFORMATION Property Address: 67 Oid Faltm Road en eltv.c e Owner:(Seuine- 7ohrizon . Date of Inspection: 7/7 5/0 j FLOW CONDITIONS RESIDENTIAL Number of bedroovis(design): Number of.bedrooms{actual): 3 C P DESIGN flow-based on"310 C1VITf 15Z5(for eitample:�I 10 gpd z#-of bedrooms): ' ' Number of current residents: .: Does•tesidence have a garbage grinder(yes br no):i10 Is laundry on a separate sewage.system(yes or.no): 00 Of yes separate inspection required Laundry system inspected(yes or no): 9 fI' Seasonal use:(yes or no):10 `I Water meter readings,if available(last 2 years usage(gp a'` 4`i Sump pump(yes or no): 1� Last date of occupancy: '` — COMMERCIATUSTRIAL Type of esta nt: a Design flgw on 310 CMR 15.203):. d Basis.of d6si'* flow(seats/persons/sgft,etc.):. Grease trap#esent(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):. nba.4, GENERAL INFORMATION Pumping Records Source of information: o' Was system pumped as part of the inspection(yes or no): OP— If yes,volume pumped: gallons--How was quantity pumped determined? Reason for.p..umping: ; TYPE OF SYSTEM , Septic tank,distribution box,soil absorption system gp Single cesspool (Lb Overflow cesspool fW Privy VA Shared system(yes or no)(if yes,attach previous inspection records,if any) (,o Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) P Tight tank. _Attach a.copy-of the DEP.approval _Other(describe): (1z Approximate age of 11 components,date installed(if known)and source of information: 191 Were sewage odors detected when arriving at the site(yes or no):V 6 _ Njo7of11 CpFIC:IA►L..•INoF EC`TLIQN-FORM,"N;QT FOR VOLUNTARY ASSESSMENTS 3VV4.VRy.XCZ fE AOr DISPOSALSY$TEM ITi .PL'QTIQN FORM PART-C - .! SYSTEM.•INFORMATION(contlnved) f3?'Q CI"Fj Add-rr$s'Y 7 Oid Taa. d 4j2rza C .G(..,..,.. Q.wa'ar: Ua one ahn Dist of 10*4`0040 4w BUILDING SEWEIf{t0azte ort•site plot) Depth baJgw.'I*V. htiteriaJs of constct or►: t4t1 , 40 PVC ether(aasplil10'. Distattac om.prtvow r vt srr sulpply watt ar suction l Co cnts(Qn castdhlgn o'f oitti4,S,Vattt) gr oyidolit to 4ge,ctt. Igo SEFTIC TANKs ✓�locztt on site P10) pV.th below grade:. ,. MA1er4l.of construction;,,4cpflcrate „ rnCtAl',,,, 0borgtus6„- polytthylcnt. c•>�sr(�cstpJsln� , j w�1C rs tttctsl J#s.t age;_,,,_ Is zgc con.v uc; by a Ccr tfioitc o 9mJ7 .tines(yts or noj: (attach a copy of ccrsiflatate) +� • ¢imtnslon.s: i���fo►„ 6�$9tar�tr�e, ��. Sludjs depth.: Qist:tnsc from t®p of s tid$c to bonont o oullct tee or baffle: $cum thicimol}."ri-ex-0. f D'astaneaftom to, "top of ouldti tee or baffle: p1.swcc.0M.0Rom:o(scum to bottom of outlet tot or baffle: Kow w.ilc ditnetfisit�tts determined: Cot�rtctrt1.Cots pwatpin.g r.ee©rtunendaRio s, .act in t?tt ei lee or baf a cottdt�lon,structural integrity,liquid levels as relate d 'QUlit(nYert,61t(:datlt6 0•(.ltil$ ,ttCi 1'"D. t2isoAs F) GREASE TRAP: (ioczte on sate play Dcpth b-940W graft Muctial.of consproatlOtt: ,canercC�j ,rnFtal�,fibcrgtzssf Wolyothylono,�othor (dxpJa(n3: . Dimon}Iotrtz: Scum tttltltttekS ..� Dlstancc boom tqp of vm o top.of outlet ale yr baffle., Phtwc from bottom of st;um to bottom of outlet its or b9filc:44t4 , Date of Last pu.np.lAg:A Catttttt.enu(ern pwmpXn reeomrttc+tdaiin:v.ltulet a�td outtlet tot or baMt condition;structural Integrity;liquid levels as related to outlet� Seri;e�idcnc���:lettk�.$�sr etc,}: � . Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address 7 U.Pd Fa2m Road en eavz e a owner: (S-2aine o neon Date of Inspection: 7 7T5/D 4 A TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete VIA metal kk fiberglass r�:polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: V1,'k gallons/day Alarm present(yes or no):ftk Alarm level: Alarm in working order(yes.or no): f1A Date of last pumping: Comments(condition of alarm and float switclie§etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) �. Depth of liquid level above outlet invert:, Comments(note if box is level and distribution to outlets equal,any evidence. f solids carryover,any evidence of leakage into or out of box,etc.): - �o PUMP CHAMBER:V UD (locate on site plan) Pumps in working order(yes or no): (�0 Alarms in working order(yes or no): Comments(note condition of pump chamber,con ition of pumps and appurtenances,etc.): 8 Page 9 of.l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART C. SYSTEM INFORMATION(continued) Property Address:6 7 O ed Fa.¢m /toad Eente2v.ii.ee Na OwnerCia.crze o nzon Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):�(locate on site plan,excavation not required) Sao. If SAS not located explain why: Type 1t leaching pits,number:_ t�leaching chambers,numbera� leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: la overflow cesspool,number: . Yb 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.). ,-o 3 qyl� • '3 .krt.. Ao)rYvW CESSPOOLS:fW (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes.or no): Comments(note condition of soil,sign of hydraulic failure,level of ponding,condition of vegetation,etc.): �r���2tti�, PRIVYAO (locate on site plan) Materials of construction: n.A Dimensions: VX& Depth of solids: VI-D, Comments(note condition of soil„signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION VORM,NOT FOR'-VOL NTARY:ASSESSMENTS SI 35URFACE'SEWAGE;IDISPt).SAL SYSTsEM-.INSPECTION:FORM PART C° SYSTEM INF•ORMATI.ON(:conti'nued)` Property. Addres�6 Cent e/LVi P P_n_ Nrl Owner:£���neohn�on Date of Inspection: 7/1 5/n 4 SKETCH OF SEWAGE•DISPOSA,L SYSTEM ' Provide a sketch of the sewage A;' bent arks.Locate all wells within 100 feet.Locate where public water supply a ters.the building. Cr; 9 A 10 P-2ge1.1ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .> SYSTEM INFORMATION (continued).., Property Address: 67 CJ-ed ;rQ2m Road C,pn Nn Owocr6-e¢in2 Johnzon Date of lospectloo: 7/9 5/04 a•• SITE EXAM Slope . Surface water Check cellar Shallow wells Estimated depth to ground water 60 feet Please indicate (check)all methods used to determine the high ground water elevation: _Obtained from system design plants on record• If checked,We gf design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: T Checked with local excavators, installers. (attach documentation) -7 Accessed USGS database-explain: , You must describe how you established th high.�gro. t! water elevation: fl e-1 T L opt � Ma Ann OM11 Leaching Pit :cct Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment I.8 ft per Frimptcr Method Therefore,the vertical.separation distance between the bonom / of the leaching pit and the adjusted groundwater table .� is .� TO-16 11 >1T+1.-ni•r•�*-TT� rn:Jrn•ntrnrv-'m'a�+T.re*�rl•.•r�tTnrrsrrT��n m�•n•v rrA'�R'y l'� R 'TOWN OF Barnstal?le WARD OF HEALTH SUIISU11FACE SEWAGE PISI'USAL SYSTEM IN811ECTION FORM - PART D •- CERTIFICATION I 1 lft1l n9*rRTTtIRTrT1RT1'1•.rirrr•r••,• •�•.^ }•••T 1•t•T••.•% -T,11 t^•ITT,K r'In'K.•I•TI T+1T lRTT1Tn1nT�•ram'.•+r,lIfllTr>♦Tt'pT"F'ATS'���~ -TIFF OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 67 Oid Faam Road ASSESSORS MAP , DiQCK AND PARCEL # 231-008 OWNER.' s NAME ,�. PART' D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME Joseph P. Macomber • &, `Son Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 _ Box To►m of Clty State t I P COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1.578 R n! CERTIFICAThON. STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true., accurate, and complete as of the time of �inspection,, The inspection was performed and any -`recommendations regarding upgrade , maintenance , and repair are consistent with my' training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; 'IV!( _ System .PASSED The inspection which I have conducted has not found any information which indicates that th.e system fails to -adequately protect public health or the environment as defined i.n 310 CMR 15 . 303 , Any , failure .criteria not evaluated Are as stated in, the FAILURE CRITERIA section of this form . System FAILED The inspection which I have .cond-voted h.as found that the system fails to protect the Eiub.lic health and the environment in accordance with Titl-e 5 , 1.10 CMR 1513Q31 and as specifically noted on PART C -JAIhURE CRITERIA of this inspection. form., ty Ir-O Inspector Signature hate i . T rT•un��=nv-r.--�-errsc's..e•�ttr� .. . ;one copy of this cjrcification must be provided to the OWNER, the 'BUYER `( where appl icabl Wj and the 130ARD OF )I EAI4TII, * I-f the inspection FAILED , the owner or op.©rator. sh-all upgrade ' the vYetem• within one year of the dcit.e of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 15 • 3.051 partd . doc AsBuilt Page 1 of 1 -SEWAGE INSPECTIONS DATE 0, :OCATION• LOTA.0_-- 0011 ASSESSOR'S MAP W.LAGE - 604 FITY — SEMJC TANK 5 g vk`,m(�r5 (sire} LEACM0 FACILITY: PO N0.OF BEDROOMS—'— ---- on BUILDER OR OWNER OWNER MAILING ADDRESS I o. D �l I 171, http://issgl2/intranet/propdata/prebuilt.aspx?mappar=231008&seq=1 ,r 8/18/2015 No. ` (19 Fee $' 50• 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS Zippfication for Miq;pozar *pgtem Cougtruction Permit Application for a Permit to Construct( )Repair(X X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 7 0 1 d Fa r m X o a d Owner's Name,Address and Tel.No. 7 8 1—7 2 9—7 3 4 7 Centerville ,Mass . 02632 10 Bacon Street C',A606/,(. Assessor's Map/Parcel 9 3/ 00 �' Winchester ,Mass. 01810 Installer's Name,Address,and Tel.No.) — — Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 Centerville ,Mass . 02632 Type of Building: Dwelling XX No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 gallons Type of S.A.S. 2—5 0 0 C h a m h p r s Description of Soil Loamy sand to honey medium sand , Nature of Repairs or Alterations(Answer when applicable) Omitting cps spools - Install 1 —1_5 n n 5, gallon septic tank, l—Distribution box and 2-500 gallon chambers packed in 4 ' of stone . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and no to place the system in operation until a Certifi- cate of Compliance has been issued y this Bo d o Hea Signed '(3 a Date 4/15/9 9 Application Approved by A Date Application Disapproved for he following reasons Permit No. Date Issued No. Fee $' 5 0. 0 C !" 6 - . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS. c 1. 01pprication for 30tgpogal *p!5tem Construction Permit Application for a Permit to Construct( )Repair(X X)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 67 Old arm oad Owner's Name,Address and Tel.No. Centeu rille,Mass. 02632 10 Bacon Street C>Q/570(') Assessor's Map/Pazcel A 9/ ©D Winchester ,Mass.01810 Instalt�r's Name,Address,and Tel.No. — — Designer's Name,Address and Tel.No. 5 0 8—7 7 5— ' J.P.Racomber & Son Inc . J.P.Macomber & Son Inc . Box 6,', Centerville ,Mass. 02632 Box 66 Centerville,'Mass . 02632 Type of Building: > Dwelling XX No.of Bedrooms '+ 3 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 355 gallons per day. Calculated daily flow U 110-3 3 0 gallons. Plan Date Number of sheets Revision Date Title ' Size of Septic Tank 1500 gallons Type of S.A.S. 2-500 Chambers, Description of Soil Loamy sand to boney meddum sand Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools. Install 1 —1.5 0 0 gallon septic tank, l—Distribution box and 2-500 gallon chambers packed in 4 ' of stone . _sf Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code aKe ZO90 to place.the system in operation until a Certifi- cate of Compliance has been issued y this Bo d o Hea Signed / /i Date 4/15/9 9 Application Approved by Date Application Disapproved for he following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ,l (Certificate of Compliance �y / ; P THIS IS TO CERTIFY,that the'On-site Sewage Disposal System Constructed('f )Repaired (XX)Upgraded( ) Abandoned( )by J.P.Macomber & Son Inc.. at 67 Old Farm Road Centerville,Mass, h Wombr constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer J.P.Macomber & Son Inc, Designer J.P,A a Son Inc . The issuance of this pe shall no, be construed as a guarantee that the systern:will function,as,designed. /y Date t Inspectors� '.` i �� -- L------------------------------ 60 No. s �f AKi Fee$ 50. 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS .i5po5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair4X X)Upgrade( )Abandon( ) Systemlocatedat 67 Old Farm Road Centerville,Mass. 9 j and as described in the,above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to '1 comply with Title 5 and the following local provisions or special conditions. Provided Construction mus a com 1 t within three years of the date of s pe t. 0 - /� 41 Date: Approved by �1f�'�` /,//U i TOWN OF BA.RNSTABLE LOCATION En f=m (2 SEWAGE # VILLAG ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 7 7 5 —33 5 I SEPTIC TANK CAPACITY LEACHING FACILITY: (ty (size) NO.OF BEDROOMS BUILDER 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 /6 U � s �' ti TOWN OF BARNSTABLE `LOCATION Cal n 10 fA ern RM SEWAGE # VILLAGE &5 n0+2 f.V 111 F, ASSESSOR'S MAP & LOicQ1—(209 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I S OC7 f LEACHING FACILITY: (ty ),% _(Z4}l�j t (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 1. r � e / 1 �! � 9y I� — -SEWAGE INSpECTION5 i DATE ,OCATION dt LOT 1 ASSESSOR'S MAP VILLAGE 9 INSFBC'p0B 1 SEPTIC TANK CAPACrrf (size) -- LEACKNO FACILM: (type No.OF BEDROOMS ®n BUILDER OR OWNER jd OWNER MA ILING NG ADDRESS t o _ �r 1 Co"1 ©iD �acm r Cenk"IIRL