Loading...
HomeMy WebLinkAbout0505 OLD STAGE ROAD - Health �u 4 Old Stage Road enterville A q 0- �0 or , 7 IN UPC llll � UPC 12534 ' No.2�153LOR �, IiAiTIliW.YM ,y i Commonwealth of Massachusetts / O— DO- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road Property Address - Oziel DeOliveira Owner Owner's Name information is Centerville `� Ma 02632 7/13/2020 required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �1..��-( o filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co „a Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sewn@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/13/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �, 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 505 Old Stage Rd Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon leach chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road v Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `. 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 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) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form - Not for Voluntary Assessments v 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.... 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 4 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 [I 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityfrown 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Re ason for um in P p 9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wV 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityfrown 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 El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system installed 2006 per town records Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: El 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.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑' No Dimensions: 1500 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" 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 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped after inspection and should be done again every 2-3 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover is on a riser. t51nsp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ,. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet inverts with no signs of past backup. Cover is on a riser 18" below grade. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � nsp 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown 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: ED leaching chambers number: 2x500 gal ea. ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown 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.): s.a.s consists of 2 500 gallon leach chambers with d-box in middle. Both chambers were video inspected from d-box and found with 3" standing water and no stain line higher. 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LV 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 I' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �. � 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 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 Lo 3 AZ 11`(fire 3y, 2jr l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cam,, 61 505 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 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: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: location on property where septic system is located is elevated compared to nearby surface water. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 506 Old Stage Road Property Address Oziel DeOliveira Owner Owner's Name information is required for every Centerville Ma 02632 7/13/2020 page. Cityrrown 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 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� M 505 OLD STAGE RD Property Address h RICHARDSON Owner Owner's Name information is A 02632 11-5-15 .. required for CENTERVILLE M every page. City/Town State Zip Code Date of Inspection I:a . Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the J computer, use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 'e"Of City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-5-15 o Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use aliht ai t time.This inspection does not address how the system will perform in the future under the-same or different conditions of use. a VS t5ins-3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET OR EXCEEDED ALL PASSING REQUIREMENTS AT TIME OF INSPECTION. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health y t and Public Water Supplier, if an ( pp Y) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i4 M ' 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4DESIGN Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 2 500 GALLON CHAMBERS WITH STONE AS SHOWN ON PLAN FOR A 4 BEDROOM S.A.S DESIGN Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: SYSTEM NOT DESIGNED FOR A GARBAGE DISPOSAL WATER USAGE FOR 2013----107 2014----131.5 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED IN 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: VARYING/MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING NOW AND AT LEAST EVERY 3 YRS Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 505 OLD STAGE RD Property Address RICHARDSON Owner Owners Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): CHAMBERS HAD WET SOILS N THE BOTTOM WITH NO SIGNS OF FAILURE OR SURCHARGE 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 El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: NOV OF 2015 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 505 OLD STAGE RD Property Address RICHARDSON Owner Owner's Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 505 OLD STAGE RD Property Address RICHARDSON Owner Owners Name information is required for CENTERVILLE MA 02632 11-5-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 5 • TOWN OF BARNSTABLE 50� L TION qG1, 4 01 Q S TA 6, FE- .20 SEWAGE # 9 CC C_" C1, LAGE C c'ry DPP Q Y 1 e ASSESSOR'S MAP & LOT I C1 C— G INSTALLER'S NAME&PHONE NO. d Jrr '1t ►` '" �'"� � ����-7r j'� SEPTIC TANK CAPACITY t i Ob LEACHING FACILITY: (type) �00C CA C�1C'AAD-4.S(size) i 7C 3T_ NO. OF BEDROOMS \\ BUILDER OR OWNER GC Qf4 PERMIT DATE: ! i ` 0 C. COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S e e A i Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 0, - 36, ' G`r � 00 3 -3s`� `r y Commonwealth,of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °Y 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name in formation is every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 squired for eve 9 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. General Information on the computer, COPYuse only the tab 1. Inspector: key to move your cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections my Company Name 19 Hummel Drive Company Address ' South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 28, 2012 Inspector's Signaturg Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form: ce Sewage Disposal System•Page 1 of 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owners Name information is required for every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes"', "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y n N ND (Explain below): N/A t5ins•11110 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is every 95 Eben Smith Road, Centerville MA 02632 Au ust 28, 2012 required for eve 9 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ 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): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owners Name information is required for every 95 Eben Smith Road Centerville MA 02632 August 28, 2012 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: _ Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 y , Commonwealth of Massachusetts NMI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road Centerville MA 02632 August 28, 2012 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑. ® Any portion of a cesspool or privy is within a Zone 1 of a.public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [Phis system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 IN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °f 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 . page. Citylrown State Zip Code Data of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site. , ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is every 95 Eben Smith Road, Centerville MA 02632 Au ust 28, 2012 required for eve 9 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 11=1,000 gals. g ( y g (gp ))' 10=23,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 1 yearDate Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner owners Name information is every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 required for eve 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: No pumping info was available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for um in : . P P 9 Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name formation is every 95 Eben Smith Road, Centerville MA 02632 August 28 2012 squired for eve 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 1/31/06 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1811+feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: 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: 6'X10.5'X6' 1500 gallon Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is 95 Eben Smith Road Centerville MA 02632 Au ust 2012 28 required for every g , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21811 Scum thickness none Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/Afeet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/ADate t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form \WSubsurface Sewage Disposal System Form-Not for Voluntary Assessments �Zzj 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required 95 Eben Smith Road, Centerville MA 02632 August 28 2012 required for eve 9 , page. City/Town State Zip Code Date of Inspection D. System Information (cont) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Capacity: N/A p gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines through speed levelers. No evidence of solid carry-over or backup in the past were found at the time of inspection. 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.): N/A Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 required for eve g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallonwith stone ❑ 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.): Chambers were found dry on inspection. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road Centerville MA 02632 August 28, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately J9 I 1 . i I O O Ai 3 = U . 2 39 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name information is required for every 95 Eben Smith Road Centerville MA 02632. August 28, 2012 page. Citylrown State Zip Code .Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 10.0'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date 5 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW 252 Zone C 47.4' 3.0'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 10.0'. Hand angered 4' below bottom of leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection was 3.0'. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17. Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 463A Old Stage Road, Centerville M- 190 P-67 Property Address Tyler Rogers Owner Owner's Name iequiredfo is every 95 Eben Smith Road, Centerville MA 02632 August 28, 2012 required for eve g page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System-Page 17 of 17 No._ Q t a Fee 00, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes AppYic tion for Zigozat *Vztem Cottgtruction Vermit w �aermit Application for to Construct( ) Repair(Y) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. A 0/0 sm G F- TZ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel � 7 'ILO may % Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. cq�r 1Gr _Zz,00 SP -YCK>7112 ye-cm r��. ,Y Type of Building: Dwelling No.of Bedrooms 3 Lot Size '7,26). sq.ft. Garbage Grinder ( ) Other Type of Building 14cp,3s�e No.of Persons I Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided "PYS gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. nj 4M?n C (2N\�- CSAU"e -S Description of Soil Nature of Repairs or Alterations(Answer when applicable) t nl S}(,,1� 'ii�1 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. S16mcu Date 0.7 Application Approved by Date A311 4 Application Disapproved by: Date for the following reasons Permit No. _3: ,C'�C� d (3 �_ Date Issued C� 00 No.. f� ,s Rid Fee t , .,„, THE COMM WEALTH OF MASSACHUSETTS Entered in computer: s a Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpp iration for Bi5po5ar �§pgtem Con.5tructfon Permit ow57 Application for a ermit to Construct( ) Repair(y) Upgrade( ) ''Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. A p/V 5T/I 6 ILR 0 Owner's Name,Address,and Tel.No. - Assessor's Map/Parcel G 7y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ^j� \ j�� �G /G svi✓r� „� sdf3-3�� 8132 wov 1G t►Jlc��1Jo�-t/Gl7 7/S�l urM o(+ Type of Building: Dwelling No.of Bedrooms 3 Lot Size 2 7,2 82 sq.ft. Garbage Grinder ( ) Other Type of Building 1-logs v No.of Persons 2- Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title {. Size of Septic Tank 15� Type of S.A.S. o9 ';M sue\\ben) c V1cwM S Description of Soil I! Nature of Repairs or Alterations(Answer when applicable) S V s*r-4 Date last inspected: l Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i 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. , Si ed Date 0 ,.? Application Approved by Date Application Disapproved by: * Date t for the following reasons r Permit No.- 6�Q0 1/0 Date Issued 3 [O THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (x ) Upgraded ( ) Abandoned( by 'Dco.e IG S A t� 4 0W at L 1 V 3 ©� 54 c J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ��b-03 dated 1 I Installer'Dno,\ zeo VD rIl� Designer V Y O P Vf t a C #bedrooms 3 Approved design flow 3 3 gpd The issuance of this permit shall ni be construed as a guarantee that the system wi fu ct of n signed. Date ' b Inspector ——————————————— ————————————————————————————— oo -0 3 J00 No. C - -- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS &.5pont *pgtem Construction permit Permission is hereby granted to Construct ( ) Rep it (X ) . Upgrade ( ) Abandon c� S 1 ( r ) System located at H &3 A 01A G E 1Z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Con tructio must be completed within three years of the da of�thi p 3 Date � Approved b -__ GJ TOWN OF BARNSTABLE LOCATION Oil) STA i✓F SEWAGE # R00 G -01 VILLAGE' Cer: #EPf i)I I 1 e ASSESSOR'S MAP & LOT C, INSTALLER'S NAME&PHONE NO. 7r.s"y SEPTIC TANK CAPACITY f i`'00 LEACHING FACILITY: (type) J at (A (size) I NO.OF BEDROOMS \ i, BUILDER OR OWNER GOrr 0-4 y �/ PERMIT DATE: I -5 i tV G COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility e n icvs Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by H,2 nor 36 7 Town of Barnstable fiHE 1p Regulatory Services . 4 Thomas F. Geiler,Director MASS. - Yublie Health Division s65.9. `e ArEDp�A. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Z -7 o Designer: STOP i -A5, 'PC Installer: •� � ;� - c�) 44 Address: g z 3 Aov7E &A Address: U cI t c'� M6L C� _ On was issued a permit to install.a (date) ' (installer) septic system at 0e-b 57vi-4e: l� based on a design drawn by (address) dated (designer) T 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. 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. ,Wfaller's Signature) i (Designer's Signature) (Affix Desi er's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE"ISSUED ISSUED UNTIL BOTA THIS FORM'AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE P - LIC HEALTH DIVISION. THANK'YOU. Q:Health/Septic/Desiper Certification Form i Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM Y, :50�*14" ) t '� ,hereby certify that the engineered plan signed by me dated 0 0 ,concerning the property located at �U A. 0Ch meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)aid two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS l and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the, maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: LL A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation32-v +adjustment for high Q.W. 4.4 — l q.'4 DIFFERENCE BETWEEN A and B /Z.L SIGNED: l" DATE: NOTICE Based uponn the above information,a repair permit will be issued for_bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASapdclpercaxexnp.doc j. TOWN OF BARNSTABLE T/ 3 A SEWAGE # Z'�°S� <'LOCTION ` fSI�S ' XX VILLAGE Cel9f��~Yl � ASSESSOR'S MAP LOT IVSTALLER'S NAME PHONE NO. lvo A 6EPTIC TANK CAPACITY ;LEACHING FACILITY:(type) f1� 17 l t' (size) OF BEDROOMS PRIVATE WELL OR PUBLIC WATER XI BUILDER OR OWNER @� �� `: .DATE PERMIT ISSUED: >'< DATE COLIPLiANCE ISSUED: N( ':VARIANCE GRANTED: Yes J ! 4� o :v No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for MigOal *p5tem CoVomUplete ion Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) System ❑Individual Components Location Address or Lot No. /O Owner's Name,Address and Tel.No. Assessor's Map/Parcel d ,"' `� � �. ,' L"& C C9 e,PL Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 14, ---O�A e- you Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons �2 Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank��`7®O 19 0k Type of S.A.S. 4/ J-90 06K,Z5 3 Description of Soil Nature of Repairs or lterations(Answe e pplicable) 1a1 � / f� QD s. t 00 On Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu of alth. Sign Date Application Approved by d Date Application Disapproved for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi!6paar *pgtem Con!Wion Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) o�mpiete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel d _-. d Installer's Name,Address,and Tel.No. Designers Name;Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbae Grinder Other Type of Building No. of Persons 41 Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank- -4 e.20 19 p Type of S.A.S. fir_o'er` �F �1/_11 Description of Soil Nature of Rep airs or Alterations(Answ;e when applicjable) Af'I— o r j Date last inspected: ` � Y Agreement: t 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 ito place the system in operation until a Certifi- cate of Compliance has been issued-by,-tl"ii, v�karzd`of alth. _ Sign ' Dateh_i Application Approved by U , -Date-'*-,. Application Disapproved for the following reasons V Permit No. Date Issued r---¢—=a ----- THE COMMONWEALTH OF MASSACHUSETTS 1. BARNSTABLE,MMASSACHUSETTS' -t W - Certificate of i mpliattce --f- THIS IS .@E'RTIFY,.that the O ii- e-Sewage Dis sal System Constructed Repaired ( )Upgraded( ) Abandoned( `by _ at e onstructed in accordance - _r with the provisions of Title 5 and the for ispos System Construction Permit No. ed Installer Aral "/W.01 Desigiier <~' The issuance of this permit shall not be construed as a gua a tee that'he system will function as designed. Date I 1 - Insp�,tor t , 0) — ———— �►a No. -- ---------------------- ————— Fee �A.2 THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS MtOaal 6potem Con!gtrUction Permit 1 Permission is hereby granted to Construct( I Repair(, )Upgrade( )sAbandon( Cj System located at ,//�., °� �' ` f�i �,d 1 a _ . . ,X A Y' Y and as described in theyabove Application for Disposal S}1stem Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructior/mq4t be completed within three years of the date of IN ermi f Dated Approved by ACCESS COVERS MUST BE W1 THIN INVERT EL E VA T l O S 6" OF FINISH GRADE 3 MAXIMUM C'CVER : DES 9' MINIMUM, GN CR / TER / A GENERAL NOTES : 92. 93 i INVERT AT BUILDING: 90. 6 DESIGN FLOW: FIRST 2 ' TO 1 . THIS PLAN /S FOR THE DESIGN AND CONSTRUCTIOK _ BE LEVEL INVERT IN SEPTIC TANK: 90. 25 4 BEDROOMS AT 110 G. P.D. PER _. MIN 2" OF PEASTONE _ t NVER T OUT SEPTIC TANK: 90, 0 BEDROOM EQUAL S 440 G. P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4" IAM PIP INVERT IN DIST. BOX: 89. 77 F IS 90.6 90. 0 U 89. 6 2 ' DOUBLE WASHED STONE INVERT OUT DIST. BOX: _ 89. 6 NO GARBAGE GRINDER 2 SE VERTICAL SEE ��TEMPLANQS•SUMED. FOR BENCH MARKS GA // . �, � 87. 5 INVERT I N LEACH CHAMBER. 89. 5 90.25 BaFr,.E 7T 8S. 5 - - _�__ BG T TOM OF LEACH CHAMBER: _ 87. 5 SEPTIC TANK REQUIRED: 3 OUTLET 2-500 GAL LEACHING CHAMBERS 440 G.P.D. X 200x - 880 GAL. 3 ALL CONSTRUCTION METHODS AND MATERIALS ANi' D-BOX W/4 ' STONE AROUND. 12. 8 •r x 33' l x 2 'd 4DJUSTED GROUND WATER: N/A SEPTIC TANK PROVIDED: 1500 GAL . MIN, MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL )BSERVED GROUND WATER: N/A CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6' CRUSHED STONE OR BOTTOM OF TEST HOLE +►l : 82. 5 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DES 1 GN PERC RATE ( 5 M)N/!IJCH PROF I L E : Nu T TO SCALE / SOIL TEXTURAL CLASS - 1 4 ALL SEWER PIPE SHALL BE SCHEDULE 40 OR / EFFLUENT LOADING RATE - 0. 74 GPD/SF APPROVED EQUAL . / 440 GPD / 0. 74 GPD/SF - 595 S.F. REQUIRED \v/ � 5 SEPTIC TANK AND D-BOX SHALL 8E REINFORCED PROVIDED: 2-500 GAL LEACHING CHAMBERS PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL ep� 1 W/4 ' S TGNE AROUND. A-606 S.F. BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE \ 1 606 S.F. x 0. 74 - 448 G.P.D. 1S MORE THAN ONE OUTLET. EN A\ 6 BEFORE CONSTRUCTION CALL -DIG-SAFE'. 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. v Q� FOR LOCATION OF UNDERGROUND UTILITIES. Ewe) 0��� \�� jI 7. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE oyo J�\y DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE Ew S O CONSTRUCTION INSPECTIONS. Ew 4��i'oF wE p A� BASEMENT FLOCR PLAN 8. EXISTING CESSPOOL 'D BE PUMPED DRY AND / Ep6E `' BACKF I L L ED. S LOT 6�s> 9. EXISTING INVERT AT THE DWELLING IS TO BE 27, 282t S. F. 96GSF SO l L TEST P / T DA TA & RELOCATED TO THE LOCATION AND ELEVATION .SHOWN. INDICATES �- INDICATES THE SEWER PIPE IS TO BE SLEEVED WITH A LARGER \Q s,o PERCOLATION OBSERVED DIAMETER PIPE FROM THE FOUNDATION TO THE TANK. TEST - GROUNDWATER EN 3 CESSPOOLS TP •I TP •2 HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 92.5 0' 92 5 LOAMY IOYR _ L04MY /OYR �• / SAND 2/2 SAND 212 91 . 8 9 . ..... . ... 91 . 8 L GAMY I O YR p LOAMY l OYR SAND 4/6 D SAND 4/6 /2' ......1 .. ......... 91 . 5 15- 91 .3 MED I UM /O YR C / MED I UM I O YR /� �•' �✓ // SAND 6/6 SAND 616 10 SEE NO TE 9. 1500 GALLON TPOI SEPTIC TANK // �' ri �� ..._ ` . CB/ON FND ?e TP* D-80 2-500 GALLON �ch LEACHING CHAMBERS \1 G 0 M/4' STONE AROUND �o 120- NO WATER 82. 5 120' NO WA TER 82. 5 BM. TOP OF CONCRETE DATE: OCTOBER 5. 2005 EL 93.04 r TEST BY: S TEPHEN HAA S PERC RATE- ( 2 M 1 N/I NCH C3a� s E- P T I C s yS TE-" v E S i 0/V 4 6 3,4 O L O S TA OE R 0,4 L7 MA P / 9 O . 4DA R CEL 6 a p ; 1 t i' , SA R IV S TAS L < cEni TER v L L E > "A � ��R' � � ILI PREP.4 RED FOR C-7 0PO o /V P Y y ■ CB 0NCRE.TE BOUND t CLS �` Q TER RANTlNE SC,4 L E / - 20 /VO VEMBER 30 2005 OS LINE EAG � � U RVEY I NG i NC IL ce:DH FND OHW-- C�YER HEAD WIRES - L{GHT POST _ 9 2 3 R o _A t o 6 A -E- L4DERGRO!/ND ELECTRIC LINE Y a r mo u t h p o r- t MA 02675 -T-- !VDERGROUND TELEPHONE LINE ,/ jl I 11 `� 5 O 8 3 6 2-8 1 3 2 gou1f Z.� � --. \ -CTV-- LUDERGROUND CABLEV/SION LINE ����/ I ( 508 432-5333 + 40.4 :'"OT ELEVATION J ` \ _._40-- E05TING CONTOUR t pol FPOPOSED CONTOUR LOCUS MAP 0 10 20 40 JOB NO 05-086A F I EL D CFW/EEK CAL C: SAH/CFW CHECK : CFW ORN: SAH