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HomeMy WebLinkAbout0171 OLD POST ROAD (CENT.) - Health 171 OLD POST ROAD Centerville A = 508 - 052 - 004 SMEAD mi No.2-153LOR UPC 12534 smwsd.com • Made in,jcVQtf0 MMUSIDMUMMMM SFINMRSOMMMUFROM CERTINED SOURCING WWWSMROGRAM.ORG LOCATION SEWAGE PERMIT NO. o VILLAGE INSTALLER'S NAME A ADDRESS I I U I L D E R OR OWNER DATE PERMIT ISSUED ( � DATE COMPLIANCE ISSUED rl' `I No. A'6I Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for Vsposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( w1u,"pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Add:ys or Lot No. 1?/ Old Page- i Owner's Name,Address,and Tel.No. `N}crvtl`r Assessor's Map/Parcel 2_p S _00 �rusN) o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. VW4b\a.5 A 1'3. r®wry 6iPS" - /5 Type of Building: h�,�t Dwelling No.of Bedrooms " I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ✓ _ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /Z e a l&C, t , 1 05 -,r s ✓i/"7 j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Q04Date �y Application Approved by Y, Date Application Disapproved by Date for the following reasons Permit No. Date C-Issued -�- -- --------- -- ----- ---- - --- - - --- - _ -- -- y No. dl ' + Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 00, 01pplication for 33isgosal *pstrm ConstCUction Permit Application for a Permit to Construct( ) Repair( W15pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Addj:9 s or Lot No. 111 01 pa 5'' rd Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a()cf-0 5;:00Lj (AS N6© Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. A rJC Type of Building: h Dwelling No.of Bedrooms I" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided K gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil c. Nature of Repairs or Alterations(Answer when applicable) Re 416 c- r 01 r/ 3G� S 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed - Date Application Approved by Date / a S- L/ Application Disapproved by Date for the following reasons Permit No, 7 O Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS &rtifitatr of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(!/Upgraded( ) Abandoned( )by 1 v G at 1 7/ I {- „ie iy, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,2 b 1 L' 3 dated 5 Installer Z)o Ds)g,c A l j✓nwN 'F-rVC. Designer #bedrooms IV 6— Approved desigpqow _,� .' gpd The issuance of this perm all not 1 e co lstrued as a guarantee that the system wi 1 'c •owa f esigned.67 Date Inspectorm// :� ,ii/l/�f. `, 1f✓ , ---------------- ----------(---/--�------------------------------------------------- ------------------------------------------------------- No. � Of--( `�"V `13OX O N I \) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem onstrUction j3ErMit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) Systemlocated;at 171 Ow YOS4' 7Zd ce.-to✓yrliP and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be c mpleted within three years of the date of this permif. %) Date - �' Approved by of Barnstable pF SHE Tpw Town ® - - A�medca Cdcy \'. ices Department i ), Regulatory Services p 111 ' r �i• ,IIA RNSTA 6LE, "Ass. Public Health Division 6gq awe m 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# 7014 1200 0001 0358 0192 September 17, 2014 Eric J. & Linda M. Krasnoo 1.017 Coolidge Street Westfield,NJ 07090 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 171 Old Post Road, Centerville, MA was last inspected on • 8/30/2014, by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution-box needs to be replaced. • Need to replace piping into and out of distribution-box. You are ordered to repair/replace the above listed septic system components 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 THE BOARD OF HEALTH T omas McKean, R.S., CHO Agent of the Board of Health • Q:\SEPTIC\Conditionally Passes Ltr\171 Old Post Rd Cent 2014.doc v htt ass 1 mtrane'ro data ParcelDetail,as z?ID=14871 - _ • F,f j Q GP P 1 P j1 live Search I Application Center(2) ®http••www,town,barnstable,,, E Application Center ®Suggested Sites• Web Slice Gallery Favorites ®Parcel Detal 1 Own BAAIt STAB 1E MA55, t ���IG39,. .,.�- I y Logged Parcel da A Detail 0 14 P 1 1 I 7 Parcel Info U Parcel 209 062 004 Developer LOT 4 ;,l ID Lot 14 Location 1171 OLD POST ROAD(MIT.) Pri Frontage Sec I Sec Road Frontage 9 Y - Village CENTERVILLE District C-0n t Town sewer exists at this Road Index 11164 address I No 4 Asbuilt Septic Scan: Interactive 209052004_1 MaP l �: �M v Owner Info �- j Owner JKRASNOO,ERIC J&UNDA M Co-Owner ? Streetl 11017 COOLIDGE ST I Street2 N, City IWESTFIELD I State NJ Zip 01090 Country h, Land Into l; Acres=.73Use jSirigleFam MDL-01 Zoning rRC Nghbd Done �i r I °d Local Intranet u lffi1011°l0°l0 •— r- 5tartli�Parcel Detail•Windows L„ j � 12,25 PM ep 0414 09:37a p.1 \C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -" 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name —'— information is required for every Centerville MA 02632 8-30-14 _ _.....— 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 ng out forms A. General Information Vk OF on t the computer, ���0� �j ......q�ss4,��� key only the tab 1. Inspector: �+-fi- �C Q � -to move your • cursor-do not = m use the return James D,Sears =o�: .TAMES e SEARq key. Name of Inspector Cape wide Enterprises,LLC _ ��•,CV Company Name 153 Commercial Street r,51t NSPEG���`��\ I ut Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-4 77-8877 S 1623 Telephone Number License Number B. Certification 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 16.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-3-14 spectar's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. / /i � t5ins•3113 Title 5 Official I Ion Form:Subsurface Sewage Disposal System-page 1 of 17 Sep 04 1409:37a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is Centerville required for every MA 02632 8-30-14 page. Cityllrown state Zip Code Dale 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: The system is a 1000 Gal.Tank, D Box and pit. Need to replace D Box and lines in and out of D Box. 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): t5 ns 3/13 7ille 5 016oial In:peclicn Form:Subsufaoe SewaGe Disposal system•Page 2 or 17 Sep 0414 09:37a p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Old Post Road Properly Address Eric Krasnoo Owner information is Owner's Name required for every Centerville MA 02632 8-30-14 page. Citylrown 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 f] ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Need to replace D Box. Need to replace line's in and out of D Box ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. 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-3A3 Tine 5 Otrdal rnspeaian Form:Subsurface Sewage Disposa;System•Page 3 of 17 Sep 0414 09:38a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M . 171 Old Post Road Property Address Eric Krasnoo Owner Owners Name information is required for every Centerville MA 02632 8-30-14 _ 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 ink is less than 6" below invert or available volume is less than day flow 7- 151ns•3M3 T W 5 Official Inspection Form:Subsurface Sewage oisposal System-page 4 of 17 Sep 0414 09:38a p.5 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal g System Form Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 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•V13 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Sep 0414 09:38a p,6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owners Name information is Centerville required for every _ MA 02632 8-30-14 page. Citylrown 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? ❑ 0 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? 0 ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ 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-3013 Rye 5 Otfidal Inspection Form:Subwelace Sewage Disposal System•Pane 6 of 17 Sep 0414 09:39a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal_ Tank, D Box and Pit. 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? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): 2012-102,0000al Detail: 2013-60,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA 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.fL,etc.): -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins',3/13 Title 5 Official trrspection Form:SabsuAeae Sewage Dlsposat System.page 7 of 17 Sep 0414 09:39a p.8 Commonwealth of Massachusetts - Title 5 Official Inspection Form VMW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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): Mns-3R3 Tine 5 OFridel Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Sep 0414 09:39a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form Not for voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page. Citylrown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1986 Permit# 66 -59. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Pipeing is 4"PVC SCH 40 House to tank. Pipeinq in and out of D Box 4" PVC SCH 20 Septic Tank(locate on site plan): Depth below grade: 8' 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: 1000 Gal. Precast H-10 Sludge depth: lit t5ins•3113 - 7itle 5 Vidal fmpeafon Form:Subsurface Sewage ofspasal System•Pago 9 of 17 6 Sep 0414 09:40a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape-Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 8" below grade. Inlet Tee,outlet baffle. No sign of leakage or over loading. 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 . I Date of last pumping: Date t5ins-3113 TIAe 5 Offidal Inspection Form-Subsurface Sewage Oisposal System-Page 1D of 17 Sep 0414 09:40a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page. Cityrrown Slate 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 t5lns.•3113 Tills 5 Ofllcial Inspection Form:Substafaee Sewage Disposal Sye.em-page 71 of 17 Sep 04 14 09:40a p.12 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 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.): D Box is 16"x 16"-20" Below grade wlone line out. Wall's are gone Need to replace D Box Pump Chamber(locate on site plan): Pumps in wonting order: ❑ Yes ❑ No* Alarms in wonting 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•3113 Title 5 Official inspection Form;Subsurface Sewage Disposal System•Page 12 cf 17 Sep 0414 09:41 a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page_ City/rown 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 Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit w/2' Stone. Pit and cover at 30". Pit is clean and dry. stain line at 1'. No sign of over loading or solid carry over. No high stain line Cesspools (cesspool must bepumped as part of inspection) (lo cate 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 .. t51ns-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 or 17 Sep 04 14 09:41 a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information is required for every Centerville MA 02632 8-30-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan)_ Materials of construction: Dimensions Depth of solids _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsins•3113 - Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 a 17 e Sep 04 14 09:41 a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Owner's Name information Is required for every Centerville MA 02632 8-30-14 page. Cityfrown 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 riACE 33 9-3 . 33` O 1 9 -31=3i � 10" O 3 t5ins W13 TWe 5Official Inspedton Forth:Subsurface Sewage Disposed System•page 15 cf 17 r Sep 04 14 09:42a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Old Post Road Property Address Eric Krasnoo Owner Ownees Name information is required for every Centerville MA 02632 8-30-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells n�v Estimated depth to igh ground water: 12'+ 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: 1-3-86 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: T.H. on Design Plan 1-3-86 no G.W_at 12'+. Bottom of pit at 8'-6"below grade. Bottom of pit at 3'-6" above T.H.Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins-3/13 Title 5 Official Inspection Form:Sibstrfac Sewage Disposal System-Page 16 or 17 Sep 0414 09:42a p.17 Commonwealth of Massachusetts ��9Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W, 171 Old Post Road Properly Address Eric Krasnoo Owner Owners Name information is required for every Centerville MA 02632 8-30-14 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 t5ins-3113 Title 5 Official mspecflon Forrn:Subsurface Sewage Disposal Syslem•Page 17 u?17