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0283 OLD STAGE ROAD - Health
283 Old Stage Road Centerville P A = 189 135 Aff UPC 12543 id0. 53LOR Commonwealth of Massachusetts / - 1 Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r , 283 Old Stage Rd v Property Address Jim and Nancy Butler { Owner Owner's Name information is Centerville MA 02632 7-24-2019 required for 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:When filling out forms A. Inspector Information 5141-- 1y6a1Y on the computer, Darrell Stone use only the tab key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return Company Name key. P.O. Box 1466 r� Company Address Harwich Ma 02645 City/Town State Zip Code �11111:7_1 (508) 240-2500 S14995 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 Furt r valuation by e Lo77-26-2019 616rity 4. ❑ Fails Inspect 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. t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 P 0 P 9 P Y 9 t C Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town 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): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora t' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 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): ❑ 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1-r 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town 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) stem S Failure Criteria Applicable to All Systems: Y pp Y 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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts �d Title 5 Official Inspection Fora �= i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. CityTrown 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 Y2 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts �b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If Y you have answered "yes"to an question in Section C.5 the system is considered a significant Y Y 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form �= F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `� % 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 2 bedroom residential dwelling Number of current residents: 3 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 Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Massachusetts Commonwealth o , x Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: Unknown 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 Commonwealth of Massachusetts i Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y Y 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town 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. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2017 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"+/- 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.): Apparent good condition t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts in Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 11" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 21" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" 16" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 1 year Recommended maintenance pumping every 2-3 years t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4j L % 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 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 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 283 Old Stage Rd v� Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 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.): Grade to box 30" Cover 12" 1 outlet Good condition No scum Normal liquid level No sign of leagage No sign of failure t5insp.doc-rev.7126/2018 Title 5 Official-Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-201 g 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: ® leaching chambers number: 1 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts �y Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 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.): 1 (500 gallon) chamber with stone (12.8x16.5x2') Grade to chamber 34" Cover e 16 Bot tom 64 Dry No sign of hydraulic failure 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.): Sinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts �T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd v Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 Commonwealth of Massachusetts yin Title 5 official Inspection Form ), Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is Centerville MA 02632 7-24-2019 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 B-( �u-�r f3 ; _ � a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts +� p Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 283 Old Stage Rd Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. City/Town 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: >5feet 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: 2017 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Elevations from the design plan Bottom of SAS ELV. 98.5 Bottom of Test hole ELV. 92.9 NWE Separation >5' 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 r - Commonwealth of Massachusetts �m Title 5 Official Inspection Form '= t� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 283 Old Stage Rd `V Property Address Jim and Nancy Butler Owner Owner's Name information is required for every Centerville MA 02632 7-24-2019 page. Cityfrown 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i t No. .9 O 1 7 a f F5 Fee ! _ V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �ez PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(W-Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. O tjDQ�T-AGe�7 Owner's Name,Address,and Tel.No. Assessor's Map/Paarrce -r�'t,l Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 2_ Lot Size 711 G:7 sq.ft. Garbage Grinder( ) Other Type of Building re5(�p�� 1 G No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date J`7 Number of sheets Revision Date Title Size of Septic Tank e'`(j S4-W t Type of S.A.S. t 5 C� CA GAOQ C, ^M w Description of Soil Nature of Repairs or Alterations(Answer when applicable) �St e�.i l Gc. &ICW D too ac C 1 1 t:J4 if Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo f Health. Signed Date Application Approved by Date Application Disapproved by f Date for the following reasons Permit No. �0 Date Issued rr '� s No. F " V ee THE COMMONWEALTH-O.F4 MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYication for MisposaY 6pstem (Construction j9ermit Application for a Permit to Construct(„ ) Repair(" Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4 g:�0 tOSTAG if T�jOwner's Name,Address,and Tel.No. Assessor's Map/Parce'}C f U LP e Cu(le 'f ,,Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. � 1G SOusN�NC. tnjS\,Nc e-/t N Type of Building: /1 Dwelling No.of Bedrooms � Lot Size /7�`C 7 sq.ft. Garbage Grinder( ) Other Type of Building (CS If Pt,-N�- !G No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow(min.required) P;).C, gpd Design flow provided 2 03 gpd Plan Date �—r, - 1-7 Number of sheets a}, Revision Date Title Size of Septic Tank P 1 N Type of S.A.S. 11503 C�C.An fit) rk",/y y- Description of Soil V Nature of Repairs or Alterations(Answer when applicable) t OWQ r CCU GC, 11,�rjArWV1 WPe c A-2 tNn LI S+taty z�' Date last inspected: Agreement:The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board_ of Health. Sign .�'�^� ....,_ Date " S( ' 17 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. r;�_0 t 14 Date Issued S t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO C RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �Upgraded( ) Abandoned( )by ���`� ( �N at j` _q Q't'- 01D has been constructed in accordance with the y-provisions of Title 5 and the for Disposal System Construction Permit Noa'Orl IY5 dated Installer t Q (`h+�l� L rtilC Designer �k h� P /t N� y�7 r) / C #bedrooms Approved(design flow ;2 �" gpd The issuance of this permit'h wil all �t be construed as a guarantee that the system l fun ti s designed. n Date �� Inspector •.,, , _-------------------------------------------------------------- No. 0 !C'1 6 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ✓ Upgrade( ) Abandon( ) System located at 2 , p I\3,t 1 P and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completedlyithin three years of the date of this permit— C � V , Date � Approved by � V l . a� r Towle of Barnstable Fire t f Regulatory Services Richard V. Scali,Interim Director * BARNSTABM 9 MASS. g Public Health Division i639• A'Fo►�''° Thomas McKean,Director 200 Main Street,Hyannis,MA102601, Office: 508-862-4644 Fax: 508-790-6304 a Installer& Designer Certification Form i l Date: sl 1-7 Sewage Permit# �l`7 I � Assessor's Map\Pareel I $l Designer: �ny`�rree��n q WO r'L(.s r l►)C , Installer: Q Va � �2� Ati. tv"Q V Address: 1Z W, C(bsjt a (d `lQJ Address: God (`f Fo re solu1� r� 6 26�i y e �� c � GCKA a Z,&?3 2 On lv C was issued a permit to install. a (date) (installer) d septic system at �OLS HLq p based on a design drawn by &e.r (address) �-1 ►� Ey►ci ine.P_<4.rci wbrGi.i 1 K C., dated (designer) ' _ I certify that the septic system referenced above was installed substantially according to the design, which may include minor.approved changes!such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soi.ts were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation.of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & :Local Regulations. Plan.revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. } I certify that the system referenced above was constriicte nce with the terms of the AA approval letters(if applicable) �rsKOF aeTER T G A McENTEE CML nsta er's Signature) "35109 t� RFG/STER i (Designer's Signature) ____.(Affix D�signer tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Forrn Rev 8-14-1 3.doc RECEIPT Printed: April 21, 2017 @ 13:31:23 BAR;.STABLE COUNTY REGISTRY OF DEEDS JOHN F.. MEADE, REGISTER Trans#: 98293 Oper:KATHLEEN JOHN SwK :li.Lw... Inst#: 1929E Ct1# <i -2017 ® 1:29:44p BARDS ;.:0 DOC C. TRANS AMT 1 f3 A r -Al OF r, RES?,il , . Count; UID 10.00 Sure. 2u.u0 Stag r:. 40.0� Surol a-r-0 :G:i i $5.00 5.00 Total fees: 75.00 ww* Total Charges: 75.00v CASH PMT PAYMENT -CASH 75.00 r Bk 30435 PS 124 g 19296 04-21-2017 01 m 2c, D DEED RESTRICTION Q� WHEREAS, of ame) MA (address) is the owner of O00 '� `� located (address) y at MA (hereinafter referred to asn -,b3 and being shown on a plan entitled "Subdivision of Land in MA, Property of et al, - — duly recorded in Barnstable�!l Count Registry of Y 9 trY Deeds in Plan Book 44Q - , Page M Or on Land Court Plan Number WHEREAS, �� I as the owner of said lot has (owner's name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr a NOW, THEREFORE, �Tdh� 1 • � does hereby place the (owner's name) following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: _ 1. d--0 Q IU �- ,\v ► may have constructed (add ) � � �� �upo the t house containing no more than w v (� bedrooms. _ e agrees that this shall be perm (owner's m �� O ' restriction affecting�© loca ed on � MA nd being shown on the plan recorded in Plan Book , Paged � . Or on Land Court Plan F r 'tl ofalgho Qtwfi see the following deed: Book I I Page Or Land Court Ce ficate of Title Number Executed as a s_ea4eo instrument day of Owner's signatur C Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS km SS'^` ' ` Y , 20_ Then persona ppear�l t e ab vee-n med known to me to��bee the person who executed the foregoing instrument and acknowledged. the same to be free act and de re me, Notary Public JENNIFER GREEN SNOW®EN My commission expires: [Ulf Notary Public COMMONWEALTH OF MASSACHUSETTS (date) My Commission Expires September 25, 2020 deedr BARNSTABLE REGISTRY OF DEEDS John F. Meade, Register TOWN OF BARNSTABLE LOCATION ,)�33 (d( j'�GQ:E SEWAGE#,P n(7 I LI S VILLAGE )\ef � ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO.` � V6n tZ l� SEPTIC TANK CAPACITYl LEACHING FACILITY:(type) ► sMgrAJCoNv(', (size) NO.OF BEDROOMS OWNER CgJ�E'_y j PERMIT DATE: 5-� - i�_ 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 BY76 G �I!� cut- 3 1' -'0 - 31 ' c� r 1 z31 of Town of Barnstable P#_ 1 5 3 a 7- Department of Regulatory Services LF$ Public!Health Division DateKAn �A 0.19• 200 Main Street,Hyannis MA 02601 Leo Mn�� .� 7q7 Date Scheduled-, - 1 C�l), W 4 Time Fee Pd. Soil Suitability Assessment for Se a e Disposal Performed By: ��` '/ I =i'1 - s i 5,LrL CA Witnessed By; LOCATION & GENERAL INFORMATION Location Address 'Z9•3 d Jc `S�'c't�j.Z. 1 Owner's Name &_.-%VC'w, `C Address Z��✓ lOQ ✓ �.e��. 12=%' Assessor's Map/Parcel: ,yq — 3 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# 6—el�'- L�--7—sr 3 i3 Land Use IZe-5 Kketfl\ \ Slopes(3'0) , Surface Stones AJcil\,< Distances from: i Open Water Body 7 3�a ft Possble Wet Area `s ft Drinking Water Well 7 7- fE Drainage Way A 1 ft Property Line ft Other_ ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Z I t 601 Parent material(geologic) y 5 Depth to Bedrock. Depth to Groundwater. Standing Water in Hole: Weeping from Pit frae1CV_qfi_E_ Estimated Seasonal High Groundwater _ 7 13 Z t/ DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: _ I Depth Observed standing in obs.hole: _in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment .,R � ft. Index Well# Reading Date: Index Well le el Aql,factor— Adj.Groundwater 1 Volro I - PERCOLATION TEST bate xlme .o Observation Hole# Time at V Depth of Perc 3 L" 99 6AJ Time at 6" T Start Pre-soak Time @ S t o1 Time(9"-6") �_ End Pre-soak Rate Min./Inch. I Site Suitability Assessment: Site Passed w Site Foiled: Additional Testing Needed(Y/N)_ Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:MPTIC\PERCFORM.DOC I DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sloil Color Soil Other L___ Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. I Consistency, % ravel A 1Z 11-3G (9 o i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture koil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ravel 9G 9® DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Munsell • Mottling (Structure,Stones,Boulders. c 'n. USDA ) Surface(t ) ) Consistency. o G ve DEEP OBSERVATION HOLE LOG Hole#-- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, I Flood Insura nce Rate Man: Above 500 year flood boundary No— Yes V:j____ Within 500 year boundary No p( Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pe v� ious material exist in all areas observed throughout the area proposed for the soil absorption system. r" I _— If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required t ing,expertise and experience descrit ed in 310 CMR 15.017. . Signature Date Q:\,ElynC�PBRCFORM.DOC COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE QFjENjyIRRONMENTAL AFFAIRS d DEPARTMENT OF ENV_IRONMENTAL ItkOTECTION RECEIVE' OCT 2 0 Z004 N OFARNSTABLE TITLE 5 TO4�HEALBH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A Q CERTIFICATION AR F y Property Address: 283 Old Stage Road 'ARCEL Centerville MA 02632 a Owner's Name: Claire Torrey Owner's Address: Same Date of Inspection: October 5,2004 Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: "o1111�F11111 _X_ Passes ;� ��• � ....Mq� H s+9 Conditionally Passes + •••may G Needs Further Evaluation by the Local Approving Authority ? TR ••t m Fails L cam; Inspector's Signature: ., �--- Date: 10/5/04 , ••'• F,�grQ*` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heaf��it���tttt�,``` IN 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 authority. DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving Notes and Comments: Leaching pit has 10"standing water with no high stains. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with / approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles S rnenortinn Rnrm 4/1 ei�nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: T41a.4q rncnaa�tinn Rnrm ail�i�nnn 3 i , Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No — _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool — _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. — _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as MR described in 310 C 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — 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. Tit1a C Tnennntinn T'nrm Ail,;i,)nnn 4 i Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 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? _X_ _ Has the system received normal flows in the previous two week period? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ 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? X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] T41a G incnantinn Fnrm Oil;i*)nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2002—40,000 gal.2003—28,000 gal.=93 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd- Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped in 2000 Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:`gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_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) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 2/11/93 Were sewage odors detected when arriving at the site(yes or no): No Title C Tncnantinn 17nr 4o gmnnn 6 Page 7 of 11 / OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1 t Materials of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 10, Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete metal fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:8.5'long x 5.21 wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet Pipe.Tank not in need of OR—MRing at this time. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titla C Tnenantinn Rnr 411 ci,)nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last m u in P P g: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): Liquid level at bottom of outlet pine no solids or high stains present PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titla S Inonantinn 11nrm All si)nnn 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 4x6 pit 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.): Pit has 101,standing water with no high stains CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: No (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.): Titla i Tnonantinn 17nrm Ail;mnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Old Stage Road F- UJ15 z�3 1000 gal tank 600 gal pit Titlo i Tncnnntinn Fnrm(.ii�i�nnn 10 Page 11 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 Old Stage Road,Centerville Owner: Claire Torrey Date of Inspection: October 5,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Back yard of property where septic is located is considerably higher than parking lot of gas station and intersection of Old Stage Road and Route 28. Topo map shows property at el.60 and town groundwater contour map shows water at el.25. Title S Tnennntinn Fnrm 4/1;i,)nnn 11 _r t COMMONWEALTH OF MASSACHUSETTS A EXECUTIVE OFFICE OF ENVIRONMENTAL AFF S aei DEPARTMENT OF ENVIRONMENTAL PROTECTION Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 283 OLD STAGE RD. CENTERVILLE LOT 6 MAP 189 PAR 135 Name of Owner EDWARD WATSON Address of Owner: 2487 CHESTNUT ST.N.DIGHTON MA.02764-1016 Date of Inspection: 4/6/99 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (608)664-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined In Title V Conditionally Passes code 310 CMR 16.303.My findings are of how the system Is _ Needs Further Eval ation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:418/99 The System Inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.THE LEACH PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.IT APPEARS THE LEACH PIT IS OVER THE PROPERTY LINE BY ABOUT 1'. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 135 Owner: EDWARD WATSON Date of Inspection:4/6/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: i have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: na 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. na The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. na Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced na The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction Is removed revised 9,2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of In spection:4/6/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nbc(approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of Inspection:4/6/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day Flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nfa. X Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy Is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 135 Owner: EDWARD WATSON Date of Inspection:416199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of Inspection:4/6/99 FLOW CONDITIONS RESIDENTIAL Design flow:-M g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):I Total DESIGN flow: 2211 Number of current residents:.Q Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: 1111199 COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nta gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:n& Last date of occupancy: Wa OTHER: (Describe) WA Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED IN NOV.98 System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa_ gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: NEW SYSTEM WAS INSTALLED IN 1993 PERMIT 93-54 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 135 Owner: EDWARD WATSON Date of Inspection:4/6199 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) nLd SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) D& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L 8'6"H 5'7"W 4'10"EMPTY Sludge depth: nLa Distance from top of sludge to bottom of outlet tee or baffle: nLa Scum thickness:iiLa Distance from top of scum to top of outlet tee or baffle:Aa Distance from bottom of scum to bottom of outlet tee or baffle: nla How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nla Dimensions: n/a Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:ji& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of Inspection:4/6/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nla Dimensions: n/a Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:-nLa_ Alarm in working order:Yes_No—: NQ Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa I revised 9/2/98 Page 8 of 11 v V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 135 Owner: EDWARD WATSON Date of Inspection:416199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If nog located,explain: Wa Type: leaching pits,number: 1000 GALLON PIT WITH X OF STONE leaching chambers,number: _nLa leaching galleries,number: _0/A leaching trenches,number,length: n(a leaching fields,number,dimensions: n& overflow cesspool,number: nla Alternative system: nLa Name of Technology: -u& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) IHL'LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,PIT WAS EMPTY AT THE TIME OF THE INSPECTION_ PIT HAS NOT HAD MORE CESSPOOLS: _ (locate on site plan) Num7er and configuration: n(a Depth-top of liquid to inlet invert: n& Depin of solids layer: n& Deptii of scum layer. n& Dimensions of cesspool: nla Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Iva PRIVY: _ (locate on site plan) Materials of construction:n A Dimensions:n& Depth of solids: n(a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n(a revi:ed 9/2/98 Page 9 of 11 v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prol erty Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of Inspection:416/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks local all wells within 100'(Locate where public water supply comes into house) n/a �U �IA LEA II �R 01 /AdS RF5 3) AC M Ate I I�l IAA 30 4 (56 3 6 PP 3� revi:.ed 9/2/98 Page 10 of 11 u- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 283 OLD STAGE RD.CENTERVILLE LOT 6 MAP 189 PAR 136 Owner: EDWARD WATSON Date of Inspection:4/6/99 NRC S Report name: nLa Soil Type: jaLa Typical depth to groundwater: n& USCS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Plea se indicate all the methods used to determine High Groundwater Elevation: _ Ot.rained from Design Plans on record X Ot served Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Q ecked local excavators,installers XUsad USGS Data Des(ribe how you established the High Groundwater Elevation.(Must be completed) USC S MAPS AND CHARTS AND VISUAL-12+FEET revi:t2d 9/2/98 Page 11 of 11 ..•, q3z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diripwial Worlw Toutitrurtion Famit Application is hereby made for a Permit to Const-tict ( ) or Repair (x) an Individual Sewage Disposal System at: Ed Vdatson -•--....-.--t .................Location ----.--•-------------------•--•----"....••... ---------------- -----------------•-r.Lo----••••---•----------------------------------- LOCI(IOn-:\ddress ...._.or Lot-No.......................................... Old Stage __Rd__--_CentQrvil_le_____________ Ow ner Address ._...._��---Robinson_.Sept c---Service----- --------- P-�O......1.08..... ]. .1 .....---------•--•-----...---•----•-- Installer Address VType of Building Size L.ot-_._-_--------------------Sq. feet ,., Dwelling— No. of Bedrooms..... ....................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building --------------------_--_._ No. of persons................._---------- Showers ( ) — Cafeteria ( ) at Other fixtures ---------------------------- WDesign 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 ( ) aPercolation Test Results Performed by.......--................................................................. Date........................................ ,.� Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ w Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 1:4 sanfi d---------------------------------------------------------------------------------.............--------------...................................... ...-- 0 Description of Soil........................................................................................... --------------•----------•------------------------------------••----------.. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•.... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ a...1..f_Q.Q.Q•--gal...s.eptic...tank......D..b.ox---and---stonepa-c]red---- ea-eh-p-it......................................... 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 rees not to place the tj system in operation until a Certificate of Compliance has bee issu d b e b rd f heael Signed �i�y/' ' :.. ............. ---............. ...Dace Application Approved By ....... ... ... ...... .. ... .......... ...... .. . ....... ... ..1.,....... .......... ...................... ................Dace........................ Application Disapproved for the following reasons- ---------------------......................................................._......................._..... . ............ ..... t................... e Permit No. ........ ... ........ .. ......... ....... Issued Dace - — ------ �""-`-°�iJ tf � .�,,r:-'�:J-.. � v.J . .. 4•`.--:r-t....�1-�v e.r�-ti.._.,..—,.,... ... ••,`.,`tea /-••.., -.�,t-^../�"` `"y:...r.�-1.�-.,�'�...J-�r - at.r� No...... :.... Fss...$.30....0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphratiun for Di!vv ml Wnr1w Towitrnrtinrt Finmit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: Ed Watson ..--•&3'-...----.•^...............Location.._Address.__.___-_______._.e—____._._._ __.._......._____.._._ ____.__..___---.or-Lot•No---•-____..............................__. 28 ... �taae Rd Centerville. . Other Address a __W.E......Robinson--Heptic Service. --------•-•-•. P.O... 1.089...Ccr�t_�xy,) = Installer Address UType of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms...... ------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ......................_._.. No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures -•------------------------------------------------------------•------------------ 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........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ DDescription of Soil-•--•-.Sand-----------------------------------------------------••--•---•----- •----------• ._... - ...................---._..........._......_........ W w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... a....�-_.-0.00...g--i---.seat;-a...tom^k......I'--?)Lox...and---0t_-n0 pp a-ck-o d----'i-aa-Ck;p4t......................................... 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 bee issued by`he Zbb ,,ardof health z57 Signed ,, :, ...........01. ..... ...... .:..;J.......------- r / ...................... ................. ._...........Date.................. Application Approved By .........�,.......... ����.............. �. � _�. . I {� Date Application Disapproved for the following reasons: ..................... .............................. ........... . .......................... ........................ .. ............................................... .................Date.................. ....................................................q...... .............�. ............................................................Permit No. ...... ,. .�. ............. Issued - ......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cnelr#ifirate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by .W j....F..._.Ro-bin.son....Sp t.i.o---Sery t e......__..... ... .......... ................------. ----------------------...-----.......................... ......... - Insrillcr at ......2.8.3.....Old.--St-ale---R. . --Con-tery -i le---------------------_..._--------- -------------------------------------- --------. ..---------------- 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. ------ ., ��. dated ..-...._........... ...............__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE'CONSTRUEA AS A GUARANTEE THAT THE ` SYSTEM WILL FUNCTION SATISFACTORY. ATE................... 1 _...... Inspector ........%. --...---------------------.---.---.-- iI THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $30. 00 No......................... FEE........................ Disposal Workv Tonotrurtion "rrmit W E Robinson-Septic---SPx`I'ca------------------------•--------------.................. Permission is hereby granted_____- .-.------.. _•-..----.. to Construct ( ) or Repair ( X) an Individual Sewag_e Disposal System 3...01-_. .t.� r• ------•------------- ���r ................................. at No.--•---�•-- .._�• � �,o---�?�------v�iZt�r�i•a_-.c�--•-- yam' as shown on the ap lication for Disposal Works Construction.! _er i No.--/Ill_________________ �.at, d . �.._....._....._......,1�...o (� Board of Health i DATE.............a . 1 ; --- -----------------•---------------••-•- I FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS TOWN OF BARNSTABLE LOCATION 9dSEWAGE # VILLAGE L ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)/e)() ,i ,fr&bsize) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER Z— lc% ,� DATE PERMIT ISSUEDbA 7-03 DATE COMPLIANCE ISSUED: .-11 9 3 VARIANCE GRANTED: Yes Now �--, t ,�, /,l �n 'v G� � (`� i � � .. � .� i, F _ a LEGEND N ® Great Marsh Rd -104-- EXISTING CONTOUR x 100.98 EXISTING SPOT GRADE W EXISTING WATER SERVICE Fo EXISTING GAS SERVICE +y" ° �a� G .F Ra a OVERHEAD WIRES ��g -&I-/,t,1- LOCUS � TEST PIT yro° 100,71 X I BENCHMARK e R, BENCHMARK BULKHEAD CORNER LOCUS MAP EL.=103.83 NOT TO SCALE 1 00 rn a EXISTING SEPTIC TANK CB TOP OF TANK, EL.=102.68f 100:9 IN (our), EL.=101.35� �L t/ Qb ;Z:�). m GENERAL NOTES: S 82 14010 W x 1 31 / G'-'" \ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL \ o 104,50 g1.00 G prox.) \ BOARD OF HEALTH AND THE DESIGN ENGINEER. 0 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 103.2 C' �- 101,5 �\ oL OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 103.47 \� �'\ 9 �� LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: 102.63 -310 CMR 15.405(1)(b): 103. x 1) A 6' variance, S.A.S. to cellar wall (bulkhead), for a 1 4' setback. \ 1112.30 �' �� 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 00 103.8 3 EXISTING oo. ` �v� TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE HOUSE(,f.2 J DESIGN ENGINEER. \ T.O.F.=103.8t LOTS & 7A � � \ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING \ > 7467 �SF FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 29 HMI-' ENGINEER BEFORE CONSTRUCTION CONTINUES. �" � �� DECK _ - 9 5 �O 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. N J Tp-1 35 102.91 LAM 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF O / �W W (approx.) W I •; HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. o 1 4 : :..� 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. TP-2 F 03,36 / 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 1,,t.'.:...: .; ti /yam / I :.' c"; :",•: 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS O 0- �f 89'. " .' ' '. \ "' AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE �' : VED pR�VEWAY; .>.. .::.. .:••. x DIRECTED BY THE APPROVING AUTHORITIES. 10 :�� 02.55 ': ;.'ii.. PA... ..:...... . 28.00 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY I' THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 102.91 6 89'5 '12t E 96y 2 SHRUBS l.. :.: CONSTRUCTION. C1P '":•. g6:55' RET. WALL 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 103.61 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 102.72 ++ E REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). N 81'39 2 0 E 9 3 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 103.29 INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. 3.21 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC EXISTING LEACH PIT SYSTEM COMPONENTS NOT SHOWN ON THE PLAN (FROM AS-BUILT CARD) TO BE PUMPED, FILLED WITH �_0 OF *SS 9 PARCEL ID: 189-135 SAND AND ABANDONED o�P PETER T. �yG�, McENTEE PROPOSED SEPTIC SYSTEM UPGRADE PLAN CIVIL 283 OLD STAGE ROAD, CENTERVILLE, MA No. 35109 REGISl- Prepared for: D.A. Brown, Inc., P.O.. Box 145, Centerville, MA 02632 S$ E Engineering by: SCALE DRAWN JOB. NO. OWNER OF RECORD 1"=20' P.T.M. .168-17 CURLEY, JOHN P Engineering Works, Inc. 283 OLD STAGE ROAD 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. �� CENTERVILLE, MA 02632 (508) 477-5313 5/6/17 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, FINAL GRADE SEPTIC TANK SHALL NOT BE AT, OR BELOW, EI.=101.0 INSTALL RISERS & COVERS OVER INLET & FOR A DISTANCE OF 15' FROM THE EDGE OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D-BOX OF THE PROPOSED S.A.S. INSTALL RISER & COVER PROPOSED S.A.S. SET TO 6" OF GRADE INSTALL RISER & COVER OVER EACH CHAMBER AND T.O.F=103.8t SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=103.1 t F.G. EL.=104.0t F.G. EL.=104.0f F.G. EL.=104.0t EXISTING\ HOUSE(#283) `T.0.F.=103.8f 3'(max.) , L _ 20, L - 5 @ S=1% (MIN.) @ S=1% (MIN.) 2" LAYER OF 1/8" TO 1/2- 4 SCH40 PVC 4"SCH40 PVC 6" DOUBLE WASHED STONE DECK 1o"I 6" aaaSaaa (OR APPROVED FILTER FABRIC) _ 14 BBBB®BB EXISTING 48" LIQUID BaaBaaa -3/4" TO 1-1/2" DOUBLE .0 LEVEL ADD PROPOSD BOX ED 4' 4.8' 4' WASHED STONE Ri? `SS J GAS BAFFLE INV.=100.77 INV.=100.60 `�� S' ,T INV.=101.35t EFFECTIVE WIDTH = 12.8' 3 OUTLETS � PROP. (N (verify) INV.=100.50 S.A.S. ao FL PROPOSED SEPTIC TANK 1-500 GALLON LEACHING CHAMBER SURROUNDED WITH STONE AS SHOWN �111 H-10 RATED TOP CONC. ELEV.=101.3t BREAKOUT ELEV.=101.00 a699 SEPTIC LAYOUT NOTES: INV. ELEV.=100.50 aaeBa 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 01630Maaaaaa INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.= 98.50 im 300M 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND E�� 8.5' 4' TRUE TO GRADE ON A MECHANICALLY COMPACTED 4' OF NATURALLY OCCURRING CTIVE LENGTH = 16.5' SIX INCH CRUSHED STONE BASE, AS SPECIFIED PERVIOUS MATERIAL IN 310 CMR 15.221(2). 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION ®®®® 0 3) INSTALL INLET & OUTLET TEES AS REQUIRED.4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE NO G.W., EL.=92.9 - ®®®®®® ® ®®®® 33" AS MANUFACTURED BY TUF-TIT_E, ZABEL OR EQUAL. 't w ® N if z ®��®®® ® ®®® ® SEPTIC SYSTEM PROFILE 102" SOIL LOG 4" KNOCKOUT DESIGN CRITERIA DATE: APRIL 20, 2017 (REF#15,327) 20" DIA. COVER NUMBER OF BEDROOMS: 2 BEDROOMS SOIL EVALUATOR: PETER McENTEE PE(SE#1542) /WITNESS: DONALD DESMARAIS R.S.HEALTH AGENT 4" KNOCKOUT 4" KNOCKOUT 58" SOIL TEXTURAL CLASS: CLASS I (EFFLUENT LOADING RATE=0.74 GPD/SF) ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH DESIGN PERCOLATION RATE: <2 MIN/IN 104.0 A 0 103.9 A 0" 0 DAILY FLOW: 220 GPD LOAMY SAND LOAMY SAND DESIGN FLOW: 220 GPD 103.1 B 10YR 4/2 11" 102.9 B 10YR 4/2 12„ 4" KNOCKOUT GARBAGE GRINDER: NO-not allowed with design LOAMY SAND LOAMY SAND LEACHING AREA REQUIRED: (220 GPD) = 297.3 SF 10YR 5/6 10YR 5/6 500 GALLON CAPACITY, H-10 LOADING .74 GPD/SF 101.0 C1 36" 100.9 C1 PERC CHAMBERS PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY M-C SAND M-C SAND 32"/50" PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED 10YR 6/4 10YR 6/4 N.T.S. >15% GRAVEL >15% GRAVEL USE 1-500 GALLON LEACHING CHAMBER SURROUNDED 92" 96.4 90° PROPOSED SEPTIC SYSTEM UPGRADE PLAN WITH 3/4 to 1-1/2 DOUBLE WASHED STONE-ALL SIDES 96.3 C2 G2 283 OLD STAGE ROAD, CENTERVILLE, MA SIDEWALL AREA: 2(12.8' + 16.5') x 2 = 117.2 SF M-C SAND M-C SAND BOTTOM AREA: 12.8' x 16.5' = 211.2 SF 2.5Y 6/4 2.5Y 6/4 Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 <5% GRAVEL ;<5% GRAVEL Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:..............................................................328.4 SF 93.0 132" 92.9 132' Engineering Works, Inc. N.T.S. P.T.M. 168-17 PERC RATE <2 MIN/IN. "C" HORIZONS 9 9 DESIGN FLOW PROVIDED: 0.74 GPD/SF(328.4 SF) = 243.0 GPD NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 5/6/17 P.T.M. 2 Of 2