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0078 OLD STAGE ROAD - Health
rl= D. / t _ UPC 12534 tt No. 2.153LOR gay A �.,.,,� ST.paS- HAS7iNGS, MN J y • a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T ................OF.....,sh-w&..,V b c � Appliratinn for Disposal Works Tonstrurtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .V0 _0251 el- ...------------- ---------------------------- ---------------------------------------------- Location-Address or Lot N Owner -----------------•-----------•----------•---Address Installer Address Q Type of Building Size Lot... ----Sq. feet V DwellingNo. of Bedrooms.______ _ .._..Ex Expansion Attic Garbage Grinder — P ( ) g ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures -----------------•---•-•--•-••..................-- .. W Design Flow......_.j`..,o........................ gallons per person per day. Total daily flow......... U 0-__-_-___-_--_...___-gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth__.__-__--_-.--- x Disposal Trench—No. .....�,. :_.._ Width.................... Total Length.................... Total leaching area-------------.......sq. ft. Seepage Pit No..,Mjgg�------- Diameter.................... Depth below inlet........._.......... Total leaching area...j3.40 I.--sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1..q Percolation Test Results Performed by.......................................................................... Date------------------------------------- 1.4 a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water._______________-____._. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........-.__........... M ---------------•------------••••--•••-•••-•-•••••---•-•••-•-•-•-•-----•--......--•--------•------............................................................ 0 Description of Soil------------------------------------- -•••----•--- •--••-------•••--••-•••-•----••--•-----------------•-•-•--•------------------------•----••-•-------•----------- Ux ------•....••-••------------------------•-----•-•-• � ! UC l' ------------------------------------------------------------------------ W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.__-•________________________________________••--__--______________-.-_-_-___.-_________-___._-. ------------------------------------------------------------------- -----------------------------•----------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b th board of lth. Signed--- -• - ---------••-................•--••-•----------•-- - Date Application Approved By----- =��.._ --------------------------------------•------•••-- --------�^ Date Application Disapproved for the following reasons:................................................................................................--------------- Date PermitNo. �............................................. Issued......................................................... Date - | � - ��- /�a� | F�E----'----- ' THE COMMONWEALTH orwAssAoxussrrs BOARD OF HEALTH ���-----��F-.,��^����^����������------_'-- | �~�� Appfiratmou� �� 3hipiia� Works Tami�4rtiou P/ rutit Application is hereby made for u Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 7� _ _ ______ _____c�__��_ __��_����_..__ __�__________����� _ ^�_ �^_______ Location Address - � = �� mnv . ----'`,-----------'----,r'-'----------------------' ------------------------------------------------ -- v°"er Ad dress � -........._- ... . -'___''--..... .......... .................................. -__-----.------'---'----_------_-------------_- Installer Address Type ofBuilding Size Lot S . feet Dwelling—No. of Bedrooms-------- ----------------------------------Expansion Attic cr ( ) Other--Type of Building ............................. No. of persons. Showers ( ) -- Cafeteria ( ) ~� Other fixtures ................................................................-_-.-_---.---__-___.-__.___________ D ' Flow......... �4...........................gJloou per person per day. Total doily 8mv.--- .--_-.---.-gallons. � 1:4S �c ]�m�--��u� �����aUouo �co�6------' \��dtb-----. D�zm,��r-----_ D�xb------ � Disposal Trench—No -- Width.................... TotalLen�6----__. Totalleaching area. ft.'- Seepage Pit I�o-/K��'-'� iameter___---- below �lct-_----_-- Totalleaching area. ft. ' �� Other D�t�bntoobox ( \ Dosing tank ~~ Percolation Test Results Performed by------------------------- Date-__-.--_--.---' � Test Pit No. L-__--minutes per inch Depth of Test Pit..-_____ Depth to ground water—_--'---,- 4, Test Pit No. 2................minutes per inch Depth of Icm Pit.................... Depth toground water--------------- � 1:4 -------------------------.-'-'_---__-_--__. .............................................................------- 0 Description o6 Soil----'-_.__----' __-.'__-�__''-''_-- _-_----'----_-_-------. ----'''''''-'--''-- -----------'--'------'-----------'---� | �� �xtoz� ofBoyu�oor �l��at�uo--�os�ec when ----------------------------------------------------------- ------- --------- ------------------ --------------------------------------------------------------------------------------------------------------------------------- -'_.----.--------.----_--_- � /^grccozcuc: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—]he undersigned further agrees not to place the system in operation ou6l u Certificate of Compliance has been issued by the board of health. ' Si -- ~ ^<� .........`~~L------------ ................................ ��. Application ^^ ~ � -------- .-_................................................. ---------------__'_,-==-�. �y Date Application Disapproved for the following reasons:.............................................................................................................. _-'-_-_-' -'--_--'_--_-_-----_'---------- ~^= Permit No........ --- u"te | � � THE COMMONWEALTH oF MAssxoeussrrs THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired Installer has been installed in accordance with the provj�sions of .' title-XI of' �lfe th e '§�Iiit'aer' �t THE ISSUANCE OF THIS CERTIFICATE SHALL NEWWCONST D AS A G6-Ai-Ai E,�THAT THE SYSTEM WILP FUNCTI9N SATISFACTORY. '6/.. * :;1.7 .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH BOARD OF HEALTH to Construct or Repair an�'irAQIA S-e�#"a"gre0�04*ids--al System � -�� 61 �Board ����h-._�__..��-^_''---- ° ` i Commonwealth of Massachusetts a Title 5 Official Inspection Form 2(1&- 03fr-001 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 78 OLD STAGE RD Property Address F�1 CURLEY Owner Owners Name information is required for CENTERVILLE '� MA 02632 8-30-17 every page. Cityrrown State Zip Code Date of Inspectio6'R Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 8-30-17 Inspector ignature Date r 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,SF all 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. City/town 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: AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. TANK WAS PUMPED IN JULY OF THIS YEAR FOR MAINTEMANCE. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USAGE. THIS REPORT IS NOT TO BE USED FOR BEDROOM COUNT OR DESIGN FLOW. 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-3f13 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 't 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every 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 y 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. 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 a d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. Cityrrown 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. Cityrrown 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 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 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? ❑ ® 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 prev report Number of bedrooms(actual): 2 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A10X30X2 S.A.S CONSISTING OF INFILTRATORS. Number of current residents: 2 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)): Detail: 2015-93 2016-249 GPD PROPERTY HAS IRRIGATION SYSTEM ALSO Sump pump? ❑ Yes ❑ No Last date of occupancy: 8-2017 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: 15ins•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 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 8-2017 Date Other(describe below): General Information Pumping Records: PUMPED IN JULY BY BARROWS SEPTIC Source of information: PUMPING Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1500 gallons How was quantity pumped determined? TANK TRUCK Reason for pumping: MAINTENANCE 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 Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every 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: 1999 PER PERMIT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1 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 per previous insp Sludge depth: light t5ins-3h3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. CityrFown 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 Scum thickness trace amounts of scum 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.): TANK WAS PUMPED IN JULY OF THIS YEAR 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 Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. Cityfrown 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every 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 O" 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.): BOX WAS LEVEL AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. THERE WAS SOME DETERIORATION OF THE INSIDE OF BOX TYPICAL FOR ITS AGE. 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: EVEN THOUGH THE AS-BUILT SHOWS A OBSERVATION PORT I WAS UNABLE TO LOCATE IT SO EXACT LEVEL OF PONDING COULD NOT BE DETERMINED. THERE WERE NO CLEAR SIGNS OF FAILURE OR HYDRAULIC OVERLOAD IN AREA OF S.A.S. LIQUID WAS FLOWING FREELY INTO S.A.S FROM D-BOX AT TIME OF INSPECTION. 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 't 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4INFILTRATORS ❑ 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.): ALTHOUGH THE AS-BUILT CARD SHOWS AN OBSERVATION PORT I WAS UNABLE TO LOCATE IT SO THE EXACT LEVEL OF PONDING COULD NOT BE DETERMINED. THERE WERE NO SIGNS OF FAILURE IN THE AREA OF THE S.A.S AND LIQUID WAS FLOWING FREELY INTO THE S.A.S FROM THE D-BOX AT TIME OF INSPECTION. SYSTEM IS 17 OR 18 YRS OLD AT THIS TIME. 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 r� 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. Citylrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M �< 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every 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 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 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 10 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: PREVIOUS PASSING INSPECTION REPORT 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 Mt 78 OLD STAGE RD Property Address CURLEY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-30-17 every page. City/Town 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 Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 :Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 78 Old Stage Road Property Address John.Boyne Owner owner's Name information is required for . Centerville Ma. 02632 12-9-14 every page.. Ckf owe state Zip Code Date of inspection D. System Inforrmation (cost.) 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 buiidind.Check one:of the boxes below: hand-sketch'in the area below drawing attached separately 0L D STAGE ZOAD i At ^ If r 9 �fiVC W0.ly Az AA - St' • A 3 q Lj Titles Ofridal Irmpsoon Form:_SLftw aA Sewage Disposal System-Page 15 cr 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne _ Owner Owner's Name information is Centerville Ma. 02632 12-9-14 required for -- every page. CRY/Towa State Zip Code Date of lnspectiort D. System Information (cons.) Site Exam: t ® Check Slope x y ® Surface water ® Check cellar I' ® Shallow wells t i Estimated depth to high ground water: >10' feet Please indicate all methods used to determine the high ground water elevation: i I ® Obtained from system design plans on record If checked, date of design plan reviewed: permit dated 8-3-99 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) I ❑ Checked with focal Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: I Ground water elevation was taken from existing records on file at Health Dept. E i } i I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ms.•3113 Title 5 O&Jal Inspection form:Subsurface Sewage Disposal System•Page Ili of 17 I I I i Commonwealth of Massachusetts ' J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1 Ins pector: �( r . r only the tab key I �. to move your Brett Hickey cursor-do not use the return Name of Inspector key. B&B Excavation Company Name 14 Teaberry Lane Company Address rremSandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification 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 12-9-14 - Insp or'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. nI15 t5ins 3/13 Title 5 Official Inspection rm: ubs.,ace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne Owner: Owner's Name iforrrefor,is reequiredd for Centerville Ma 02632 12-9-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below: Comments: B) System Conditionally.Passes: ❑ One or more system components as described in the "Conditional Pass section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. W. 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 Ieaking 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 (. Commonwealth of Massachusetts = v Title 5-Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne Owner Owner's Name information is Centerville Ma. 02632 12-9-14 required for every 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 breakout 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 ❑ (Explain ): .Y. ❑ N :❑ ND. Ex lain 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 ❑ Np (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 v Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form=Not for.Voluntary Assessments 78 Old Stage Road V Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrrown 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 1he 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 El ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due town 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 Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 78 Old Stage Road v Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrown State Zip Code..: Date of Inspection B. Certification (cont.) Yes No El ® Required pumping morethan 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ .0 Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z 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- 1 0,000gpd, 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 El ❑ 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. l5ins•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 .�' 78 Old Stage Road Property Address John Boyne Owner. Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrrown State Zip Code, Date of Inspection C. Checklist Check if the following have been done: You must indicate"yes" or`"no° as to each of the following: Yes No ❑ 0 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? ® ElWere 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? 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 ortees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupantsif 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::Forexample, 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 Inspectionform Subsurface Sewage Disposal System Form Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrrown 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 E 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 (gp ))� Detail: 2013 19,000gallons 2012 27,000gallons sp Sump pump? ❑ Yes ® No December 1 Last date of occupancy: 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 78 Old Stage Road Property Address John Boyne Owner Owner's Name information is Centerville Ma. 02632 12-9-14 required for i every page. Cityrrown 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 El 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. I, ❑ Other(describe): t5ins,•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments .y 78 Old Stage Road Property Address John Boyne Owner. Owner's Name information is required for Centerville Ma. 02632 12-9-14 every 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: 1999 . Were sewage odors detected when arriving at the site? ❑ Yes ® No. Building Sewer(locate on site plan): Depth below grade: 2 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 no sign of leakage. p. Septic Tank(locate on site plan): Depth below grade: 1 -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 gal. 2" Sludge depth: ' t5ins•3/i3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne Owner. Owner's Name information is Centerville Ma. 02632 12-9-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (eont.) Septic Tank(cont.) 3411 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6 13„ Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last.pumping: Date t5ins,•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary.Assessments 78 Old Stage Road s Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 42-9-14 every 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): 9 9 ( P P p ) ( P ) 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Old Stage Road Property Address John Boyne - Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every 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 deteration, or 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 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 78 Old Stage Road _ Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - -- Type: ❑ leaching pits number: 4 hi cap. infil. ® leaching chambers number. (10'X30'X2') ❑ 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. Infiltrators were dry when video.inspected, 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 78 Old Stage Road Property Address John Boyne Owner Owner's Name information is required for Centerville Ma. 02632 12-9-14 every 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.): ii t5ins,•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Old Stage Road Property.Address John Boyne Owner Owner s Name information is Centerville,.required for.: Ma. 02632 12-9-14 every page., CitylTown 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 wherepublic water supply,enters the building. Check one of the boxes below: hand-sketch'in the area below drawing attached separately OLD STA(oE QOAD I A( - A ?)A Zo` 2- - Zz.'c." 63 - 36 y . s 0 y -GAGE. t5ins•3/13 Title 5 Official.inspection Form:.Subsurface Sewage Disposal System Page 15 of 17 i Commonwealth:of Massachusetts Title 5-Official Inspection: Form e Subsurface Sewage Disposal System Form Not for Voluntary Assessments M .�' 78 Old Stage Road Property Address John Boyne Owner:: Owner's Name information is required for Centerville Ma. 02632 12-9-14 :.. : every page., City/Town State Zip Code. Date of Inspection D.'System: Information (cont.) Site Exam: ® Check Slope . Surface.water Z Check cellar . ... ® Shallow wells _.: >10' Estimated depth to high ground water: 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 dated 8-3-99 Date Observed site (abutting property/observation hole within 150 feet of SAS) 0 :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: Ground water elevation was taken from existing records on file at Health Dept. 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 yt 78 Old Stage Road V Property Address John Boyne Owner: Owner's Name information is required for. Centerville Ma. 02632 12-9-14 every page. City/Town .:State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked I ® 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 i t5ins:•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _i!< Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppricatiott for Mie;/pogar *pgtem Cott5tructiott permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) /Complete System ❑Individual Components Location Address or Lot No. >Q' ®l� C z�e 4 ' Owner's N e,Address and Tell..No. Assessor's Map/Parcel /v i 0 # 9"P 4( — Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. */1//o � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(-11� Other Type of Building No. of Persons Showers( ) Cafeteria( ) • Other Fixtures • ."Design Flow L9 gallons per day. Calculated daily flow 3 3t� gallons. 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his o f lth. / �Q Signed Date 7` Z��/ Application Approved b Date Application Disapproved for the following reasons Permit No. `'°' Date Issued � r J -- li No. 'r' Fee V THE COMMONWEALTH OF MASSACHUSETTS _ Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS Yes Z[ppYication for Migoml *p!5tem Construction Permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) L"J Complete System ❑Individual Components Location Address or Lot No. Owner's N e,Address and Tel.No. er J© �© "�e Assessor's Map/Parcel G D h1'71el'G////0j Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o�/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(1140 Other Type of Building It-1-51 Pwe? No. of Persons Showers( ) Cafeteria( ) - - Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title j Size of Septic Tank 4 i�9'40� Type of S.A.S. lDX 3Dil'Z. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: ' 1 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by,4his Bo of lth. -- ti Signed Datew- - Application Disapproved for the following reasons r t Permit No, "' Date Issued - —————————————————————— r THE COMMONWEALTH OF MASSACHUSETTS ZO '—�J7i BARNSTABLE,"MASSACHUSETTS E ;rt Certificate of Compliance THIS IS TO CER2ef Y,that th Ong-`ite Sew ge Disposal System Constructed( )Repaired ((/Upgraded( ) Abandoned by / 7Z// ` ei1-5� ��1 at D S q r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "� dated Installer Designer p The issuance of this pe t(hall of be construed as a guarantee that the sy ill I ctio�.f as es g d. Date Inspector �+ f - —————------------------------ 4if Z --��---- 1-- No. +� Fee THE COMMONWEALTH OF MASSACHUSETTS = PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS M!6pogai *pMem Construction Permit Permission is hereby granted to Construct )Re air(V_�Upgrade( )Abandon( ) System located at / !r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction mustbe completed within three years of the date of this t. Date: s J Approved 4y `' i . S u&199 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 PERINUT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 712-7/�9 concerning the property located at 71� /25:/ meets all of the following criteria: 4/ The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. '� T'ne soil is classified as CLASS I and the percolation rate is less than or equal to - � minutes per inch. ere are no wetlands within 100 feet of the proposed septic system '/There are no private wells within 130 feet of the proposed septic system Y There is no increase in flow and/or change in use proposed e,e are no variances requested or needed The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor ethod when applicable] Imif the S.A.S. will be located with 250 fees of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maxdmum adjusted groundwater table elevation, Please complete the following: �( A) Top of Ground Surface Elevation(using GIS inform Z ation) 6 Z - B) G.W.Elevation �V +the MAX High G.W. Adjustment. (O6 7 = DIFFERENCE BETWEEN A and B SIGNED : DATE: 7 [Sketch proposed plan of system on back]. q:health folder.art ov G Ge� 935 7-01 ✓ TOWN OF BARNSTABLE LOCATION / T 0119 SEWAGE # VII,LAGE G�P.dIYZ°/ l� p ASSESSOR'S MAP & LOT Z _"' �W INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 6'0 0 LEACHING FACILITY: (ty ) (size) CPS 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 p (ZeAK Owe-I I;Ll Al Z6 13, - 22' A1�a�" oz- V, - 133- 33'