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Home My WebLink About0139 OLD STAGE ROAD - Health 139 Old Stage Road Centerville A--'-' 189-086-001 X SMEAE No.2-153LOR UPC 121LU IrtWMt�M01NIL7W LOISAII 0'�`„o'ao 101'H'°'° comwo �1►+e rgyy Town of Barnstable ent Inspectional Services Departrn PrfDMv`�� Public Health Division 200 Main Street; Hyannis MA 02601 1 homas A McKean.l 11l) Utticc 509-802-4644 FAx 509-790-6304 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPdAI► 15 Moo)R FAILED SYSTEMS (-vown Code §360-44 An ,-x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the. last year not due to clogged or o,�slructed pipe. > >ed SAS or cesspool I of sewage into the house due to an overloaded or clogged fxaol ci Backup ❑ Structurally unsound septic tank or SAS ONE ] PEAR DEADLINE CRITERIA►s above the outlet invert due to an ❑ Static liquid level in the distribution box overloaded or clogged SAS or cesspool ❑ ool. or privy is below the high groundwater elevation A portion of the SAS. cessp cesspool is located within a Lone 1 to a public well A portion of the A portion of the cesspool is located within SU feet s empra se If the water analpply ysis with no acceptable water quality analysis. 1 I h►s _) p indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any `conditionally passed systems" (broken cover; relocation of a pipe, relocation 01'a driveway due to H-10 components; etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Mown Code §360-20 h) OT_ ❑ I eeJ Q� ' - v I- 3h ---- - --- Repa►r deadline:_ ----- - — - --- - ---- _..._. ---- 0\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS doc I � Commonwealth of Massachusetts r8R-o8�-0o r r _ ,�p Title 5 Official Inspection Form '= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v— 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is Centerville ✓/ MA 02632 06/02/2021 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address IL R Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 06/02/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. Lt5insp.,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form '= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L � 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �ry Title 5 Official Inspection Form r5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Road L� Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): At the time of the inspection the concrete baffle on the discharge side of the septic tank was missing. ❑ 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): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c V � 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Road u- Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �1 Title 5 Official Inspection Form �r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l� 139 Old Stage Road v� Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 plus Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2020-43,000 gallons were used and in 2019 - 81,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form Ir Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Road V� Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: flow Design based on 310 CMR 15.203 g ( ) Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts x Title 5 Official Inspection Form �T Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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. r ri❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l� 139 Old Stage Road V Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 28"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 H-10 1500 gallon Dimensions: Sludge depth: 4 11 Distance from top of sludge to bottom of outlet tee or baffle baffle missing Scum thickness 1" Distance from top of scum to top of outlet tee or baffle baffle missing Distance from bottom of scum to bottom of outlet tee or baffle baffle missing How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was missing. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts ' m Title 5 Official Inspection Form '= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r; 139 Old Stage Road v� Property Address Justin and Nicole Saunders Owner Owner's Name information is Centerville MA 02632 06/02/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `F 139 Old Stage Road u Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 nf Commonwealth of Massachusetts it Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Road v' Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form '= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............« � 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Road v— Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I, a' 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is Centerville MA 02632 06/02/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14- 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 a too se i 1 Q �C n o ;3• -p.3a 0,- aF oG E-5s' 57 G 6�. i i i t5insodoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c � Commonwealth of Massachusetts x Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I� `.............. 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is Centerville MA 02632 06/02/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 16 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 'T? " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 139 Old Stage Road Property Address Justin and Nicole Saunders Owner Owner's Name information is required for every Centerville MA 02632 06/02/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. , — 73 1P FEE /u 9 111/ COMMONWEALTH OF MASSACHUSETTS � ✓ C/ /?`s Board of Health, , MA- APPLICATION APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair4Upgrade( ) Abandon( 0 Complete System dindividual Components Location Oldi Owner's Name q de Map/Parcel# INPU, Qo Address ' W Q Lot# Telephone# 3(2) Aa Installer's Name Designer's Name N a Addres � ® Address Telephone# ocl rol Telephone# Type of Building v G Lot Size sq.ft. Dwelling-No.of Bedrooms Pr Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) I JA gpd Calculated design flow Design flow provided NIAgpd Plan: Date Number of sheets_ Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS A-K) Ir-)IiJ The and igned agrees to instal a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ees to not to plat system in OF u a Certificate of Compliance has been issued by the Board of Health. Signe Date ll iCa�'hU-L a c� ��e Cv 2:3 z Inspections Now � 1 ` ! FEE 7 ... ,. , --COMMONWEALTH OF MASSACHUSETTS / 7 8_ `s Bo C�lJtat 1` ard of Health, w&, , MA. r�, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT � Application for a Permit to Construct( RepairdUpgradeO Abandon( - ❑Complete System Individual Components> Location] R aCk J q, `b Owner's tNa(m'e kN('o f>,l>f's . Map/Parcel# Iqq ,,, oh.- � Address Mc, 06 slog 1 (V. ,W 14.1 ' Lo[# q Telephone#3(!) t Installer's Nam �� ( r.,�� Designer's Name I �1l^> Addres (�{ 0� v �v Address Telephone# 114 dl`, i (q(q Telephone# Type of Building ''^'�rl � n(A 1 nn Lot Size sq.ft.. Dwelling`=No.of Bedrooms N i'T Garbage grinder ( ) 1 ,r Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures / Design Flow (min.required) gpd Calculated design flow Design flow provided NI 4 gpd f Plan: Date Number of sheets Revision Date Title Description"o`f Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation a DESCRIPTION OF REPAIRS OR�ALTERATIONS WA) 1 { CA ' ." ,rl`l/ Y i t The undo-signed agrees to instd1 tthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5.and furtheragrrees to notto plac-the system in operation til a Certificateof/Com fiance has been issued by the Board of Health. Signed! =�-�1--�. Date V I l� �� a 23 Z c a Inspections P (sC OO()C'.)oo UC ou CO GcQC,O%.00JJq,Po,?Cc oo`00:.0C.000C CC C O COO Coo CC)COooC CC OOo,C O�^OGGG,C:,C_ U C;o,.J CC O,;U..QC Uc.Ot.;, oo l.(:1.G.. No. "` t r FEE s' COMMONWEALTH OF MASSAC14USETTS Board of Health, �""1 ,MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ('},Upgraded ( ),Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5),and tth�rlapproved design plans/as-built plans relating to application No. `' ��fit' dated c �-;r Z i . Approved Design Flow ry!J�" (gpd) !Installer .�.1-��"�ItM / Iq "J �- 1! 21 Designer: �1f a'"1�P1 tiv/ 1'q' �Y Inspector: / [%� �'v/ Date: The issuance of this permit shall not be construed as a guaranteethat the system will function as designed. r �CCC0000C:C.)pCJ000000<i00V 0000U OGC GOUGOCODUOC.O<`,:':rJJC�.' �CG00010CGUUQOGC`. 1=(�(:JOCC(:GOJGC GC.>GC•JCCOG OGUVJ "'].;C;0.1U( '� i c•.c (<'1'•i;i�GG;�' No. '';Z (/ FEE e C®MM®NWILAI.TH OF MASSACHUSETTS Board of Health, ,MA. r DISPOSAL SYSTEM CONSTRUCTION PERMIT, t Permission is hereby granted to; Construct( ) io=''"t Repair( ")Upgrade( ) Abandon( ) an individual sewage disposal system at ! 0�0 5T�l�' �� 6411E_ 1'y`/-�t as described in the application for "'Disposal System Construction Permit No. - 192J-71>( dated _Provided: Construction shall be completed within three years of the date of this permit. All locaixonditions must'be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Chaddom,MA Date Z '�� Board of Health No...`� // 30 00 + ��o Fss.... ....................... APPROM THE COMMONWEALTH OF MASSACHUSETTS B nst Conte BOARD OF HEALTH TOWN OF BARNSTABLE �/ c� �$- 00 �P �gnod Appliratiivit for Diripimal Works Tomitrtartiuit ramit Application is hereby made for a Permit to Construct ( ) or Rcpair NX ) an Individual Sewage Disposal System at: 139 01�1 Sta. e Roa' Centerville - ............................r..........-•••----••••---•----•••--•----......•....--••---_-•--. -••---•-•---•-••-•••----•••-•---•-•--••-•------••••••••---••-••-••••---•-----......---...----..... Location-Address or Lot No. Culver e j W J.P .Ma.comber Jr . Oncr Address Installer Address UType of Building 3 Size Lot............................Sq. feet �. Dwelling— No. of Bedrooms.................•._._._.._...-----------.-.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---_-------_------._-...... Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------------...................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench— No. .................... Width.............»_._.. Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..---------_----.-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit._.._......_.._..... Depth to ground water........................ fs Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ----------- --------------------------------------- --..-.----•--•••............. ------------- ----------- •... •--•----------•-•_-----. --..... -......... 0 Description of Soil--•-••--•-•------•••--••.....-••-•-•-•--•-•snn`..&...Crav 1 2 ---- ---------------------•---••--- V ................................. .............................................................. --•••-•••••••------••--••••••-••.......-••••.............•••-••..........................._......-•••••- W -•-----------------------------------------------•----------------•......•..................... U Nature of Repairs or Alterations—Answer when applicable........Omit—C e s_s v o o 1_s____I lion ten' 1—distribution 'fox and 2-1.000--_gallon-_-leac;l..-pits--_.•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia ce has e issued by th boar of health. Signed ...... o'...... ---------- ............................ .....4/2.5./9^....:...... Dace Application Approved By ............ ........... ... ,,...a'L... ..��..... ..................... car.. .Dare f Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------- .................... ...................................................................... .... .......................................................... ........................................ PermitNo. --------. ..:,.....a..Q...4., ................. Issued ........................................ Dace OOOCFEz THE COMMONWEALTH OF MASSACHUSETTS � 1 ,1 BOARD OF HEALTH ��TOWN OF BARNSTABLE ,-f i ) 00 v Aji�ftrativn for Diri nsal Marks Towitrnr#ilan Vanfit Application is hereby made for a Permit to Construct ( ) or Repair 1'(X ) an Individual Sewage Disposal System at 139 Old Stage Road Centerville ...... ---- -----..._•-•----------------••------ •----••-••••--------------.....------...........----•------•-•----------........................-- Location-Address or Lot No. Culver ......------------•--•-•-------••-•----•---•-----•-•--...•--•------------------------ ••----------•-------•••••-----•--------•----------.......--•---•-----•-----...........---.....•... W J.P.Macomber Jr. owner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling X No. of Bedrooms-----------... ------------------------....Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) - Cafeteria ( ) QI Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................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..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................•-------••-•••-••-------•-•--•-•-•---••••-•-•--..... Date....-----------...........-----......... 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ••••••-•--•-....•--.......••••-••-•....---•-•-••-••---••.....................•--•---••-••-•---••-•--......................................................... 0 Description of Soil.............................................Sand__&___Gravel x -•---------------•------......---•--.......................--••.................---...... w 1 U Nature of Repairs or Alterations—Answer when applicable.......--Omit Cesspools_ _ Install 1-15 0 0 ---------------------•---------------- gallon tank 1-distribution box and 2_--1000 gallon leach pits . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,issued by the boar of health. Signed�/Ilir�I, � !/<�-� t! ... ....,r.............. - -- 4./2 /94....:...._ Application Approved By ............ e � ...._�/.v.,)..�..<.-......=-� Application Disapproved for the following reasons: ..........................................................:............................................................................. PermitNo. ..........-t.-L1- ... .................. Issued .................................................. D�........ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertifirate of C�ontplianre _THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX ) + .p.Macomber .r. by ...............:.. ...... - ............. .... - Insr.Jlcr 139 Old S`i.gc road Centerville at ............................................ ............ ........... ............-------------------------------...-------------.......------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....-?.y-... . ........... dated .--.._....................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... '"~..... _..".... ._.......:......... ........--........ Inspector ...-, . 1 1. 1.�.-..�............ io" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... FEE.. .... TOWN OF BARNSTABLE 30 00.C��1-. ,�� ............ �i��n�tt1 �ark�� .uatn#roan �rrnttf Permission is hereby granted.-.J.-p--,q-.r-ojnbP r..Az...............--..._..........._.._. to Const uct ( 2 or Repair (XX) an Individual Sewage Disposal System 3y 0 d Stage Road Centerville atNo. ..---- •---•--- -•----•--......... Street as shown on the application for Disposal Works Construction Permit Nai-....�- ---- ..- Dated.--..- 61................ Board DATE ...-..a L of H ealth FORM 36508 HOBBS&WARREN.INC..PUBLISHERS Health Master Detail Page 1 of 1 1 He Its Jl�.- t r Logged In As: TOWN\health Health Master Detail Thursday, August 30 2012 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 189-086-001 Location: 139 OLD STAGE ROAD, CENTERVILLE Owner: CULVER, PHYLLIS E I i( Business name: Business phone:17718691 I Rental property: ri Deed restricted: r Number of bedrooms : Contaminant released: r' Fuel storage tank permit: F Save Parcel Changes I Return to Lookup , Parcel Info Parcel ID: 189-086-001 Developer lot:LOT A Location: 139 OLD STAGE ROAD Primary frontage: Secondary road: Secondary frontage: Village:CENTERVILLE Fire district:C-O-MM Town sewer exists at this address: No Road index:1174 Asbuilt Septic Scan: 189086001_1 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: CULVER, PHYLLIS E Co-Owner:C/O JANE CULVER Street1:95 OLD CONCORD ROAD Street2: City:ST JOHNSBURY State:VT Zip: 05819 Country: Deed date:03/24/1987 Deed reference: 10663/301 Land Info Acres: 0.50 use: Multi Hses MDL-01 Zoning:RD-1 Neighborhood: 0105 Topography:Level Road:Paved utilities:Public Water,Gas,Septic ® Location:Rear Location Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1900 3418 1586 Bedrooms2 Full 2 1900 728 1584 2 Bedroornsil Full Buildings value:x168,200.00 Extra features: m21,500.00 Land value: o110,300.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?fD=189086001 8/30/2012 Map Page 1 of 1 Town of Barnstable Geographic Information System New Search Home I Help Parcel Viewer F Custom Map Abutters Map size ® 13 Zoom Out In 1.-..... Full — a ;t r; +� - a N _ ® (9 3PG Map: 189 Parcel: 086-001 Property 4189080 Location: 139 OLD STAGE ROAD Info a:153 189090003 200089 a202 1 p 158 M300 Owner: CULVER,PHYLLIS E a30D 189088 LOCdtIOn IOformation i a 140 09088001 Map&Parcel 189086001 2 a 142 Location 139 OLD STAGE ROAD Acreage 0.50 acres 9` 18At18007 124 1 C--urrent Owner ---------- -— Mailing Address CULVER,PHYLLIS E C/0 3ANE CULVER 18A087 1890800D1 `. 95 OLD CONCORD ROAD a'1a3 a 139 F ST JOHNSBURY,VT 05819 09070 4128 C Appraised Value(FY 2012) 189080002 ®a 141 o Extra Features $21,500 K 189118006 o Out Buildings $31,000 y a3e p� 2112�t Land $110,300 ® �{„ Buildings $168,200 Total Appraised $331,000 ; 2090D1 w4 18A 118005 189169 209072 Assessed Value(FY 2012) 0 a98 3 Feet' a 118 Extra Features $21,500 w Out Buildings $31,000 , Land $110,300 }ti Buildings $168,200 Set Scale 1"= 83 Aerial Photos li I MAP DISCLAIMER Total Assessed $331,000 _1 Copyright 2005-2010 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS BarnstableMA v1.2.4379(Production) http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=189086001 8/30/2012 vk 212J11 oz- v 66 77.31' VIP Q, 3 41 �1r ' L=15.47 ry 41. Q.O N ^ t 3• n� o L=21.62' n tblei Cb Oq 61.52' LOT.B' Cb 10,001.5 f S.F. 10.6 0' m 10.9, V co N EX►SflNG FOUNOAnON 88.50' OF ROBIN V ILLIAM cGi MLC,OX m t� 31341 TOP OF FOUNDATION IS ELEVATION 100.7 (SITE PLAN DATUM). TO THE BEST OF MY INFORMATION, "AS-BUILT' PLOT PLAN KNOWLEDGE, AND BELIEF THE BARNSTABLE, MASS. FOUNDATION SHOWN ON THIS PLAN (CENTERVILi.E) PARCEL W. PL.EK.391/100 HAS BEEN LOCATED ON THE GROUND DATE 5/27/11 SCALE 1� = 60' AS INDICATED JOB 6967-00 CLIENT DUBUN SWEETSER ENGINEERING 5 27 11 203 SETUCKET ROAD DATE PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660 OFF. 508-385-6900 FAX. 508-385-6991 C: I S8 I PROJ 1 6967-00 1 dwg 16967-APP-,01.D.WG 0 2011 SWEETSER ENG. ` Commonwealth of Massachusetts JJ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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. A. General Information 1. Inspector: I . , Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification -a ,a I certify that I have personally inspected the sewage disposal system at this addr s and thatt the information reported below is true, accurate and complete as of the time of the inspection. Thy insge�etion was performed based on my training and experience in the proper function and mailntenanceJpf on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section M340 R Title 5 (310 CMR 15.000).The system: 70 k ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-1-12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 01 �['b t5ins•11/10 Title 5 Official InsJb.nVubufa.e Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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: System is in good working order with no sign of failure. 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-11110 Title 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 wM 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 } Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y 2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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 2000 d- . ❑ ® Y P g Y 9 9p 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 11 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 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 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 7-2012 Last date of occupancy: Date 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•11/10 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 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® . Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 44"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 36"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 Sludge depth: 12" t5ins-11/10 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 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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 20" 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 6-1 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts = W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): i 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town 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.): Good condition with water at working level and no sign of back-up from pits. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Eq Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Both leach pits were empty at inspection with pit G having no visible stain lines, and pit F having a stain line at 30" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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.): t5ins-11/10 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 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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 B jSfe edl g e Q -30 ' A -� ,� F- A 6 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments se`'y 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 139 Old Stage Rd Property Address Phyllis Culver Owner Owner's Name information is required for every Centerville MA 02632 7-31-12 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 I t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 / TOWN OF BA RNSTABLE LOCA'I N ��I ®/mil �7� 2 SEWAGE # VU_LAGE Cent f e�y I'll ASSESSOR'S MAP& LOT — INSTALI,EXS NAME&PHONE NO. SEPTIC TANK CAPACITY 45 L O LEACIiTNG FACILITY: (typa) f ''1L.S (size) !I 7 . NO.OF B E®ROOMS_ ,_....:..., B- UIL D,ER OR OWNER, PERMIT®ATE: COWI.MCE DATE-- Separation Distance Between tbe: 1 Maximurn Adjusted Groundwater Table to the Bnuom of Leaching Facility Eeei Private Water Supply'VkH and Leaching Facility (If any wells exist on site oe doilthin 200 feet of leaching facility) Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching,faclta ) -.-— Fee Fur►tislaed by IN� e j5l� back Cd7�w q e +104 Se a' A - G- 6�, TOWN OF BARNSTABLE LOCATION l3 9 04,0 S?'A- 6 c x y• SEWAGE # VILLAGE G +e.t/feof VI-1 4 c ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ,T/� M ,I G aA4 ,ecR SEPTIC TANK CAPACITY /.d"o O LEACHING FACILITY:(type) A P/T $ (size) /4 00 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BAR OR OWNER DATE PERMIT ISSUED: -- .- �` DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No G� r. -� O ____ c�� ` 4 � ;� � f �f, �` sr 8�5 � �.� � �i� � �` r !4 dF �j�'4 "`� � 1 YJ � � i �� }, :r � .. p � Y b ,. � , �` �' � �� Y-o,,,ppp�� fir` ��