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HomeMy WebLinkAbout0599 OLD STAGE ROAD - Health 599 OLD STAGE RD., CENTERVILLE A = $ air UPC 12534 No.2� 153LOR HASTINGS. )IN i TOWN OF BARNSTABLE � LOCATION � � / N?4-"7� 20 SEWAGE # /�91 VILLAGE C-1 A 1� �^ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. .: SEPTIC TANK CAPACITY LEACHING FACILITY_ : (type) I_'� �S (size) ACAJ Sloe NO. OF BEDROOMS LiP BUILDER OR OWNER &) ®4. I'I Vw PERMTTDATE:�r, �7 / �I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility,(If any wells exist on site or within 200 feet of leaching facility) eet Edge of Wetland and Leaching Facility(If any wetlands exist within-300 feet of leaching facility) Feet Furnished by h B vi d �' a TOWN OF BARNSTABLE - ,t?CATION • -` I ©/ SEWAGE # ASSESSORS NSTAL.E S NAME&PHONE N0. ;EPnC TANK CAPACITY -" .EACHING FACILIW: (type) � r 5 (size) 'ERMITDATE: COMPLIANCE DATE: separation Distance Between the: 4axim«m Adjusted Groundwater Table to the,Bottom of I.eaching Facility _ eet !rivate Water Supply Well and Leaching Facility (If au►y wells exist on site or within 200 feet of leaching facility) idge of Wedand and Leaciting Facility(If any wetlands xist within 300 feet of eaclaing faci'ty) urnished byS=wH —�to G s. -D-s 1 � 't No. ' Fee 1 V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for i( ai *patent �Con5truction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. (.l (�` S4G.[y� Owner's Name,Address and Tel.No. Assessor's Map/Parcel �Ck\ _ r.�r\ r gy �� (/ �I Iystaller's Name,Address and Tel No. l/\J Designer's Name,Address and Tel.No. �t Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(A Other Type of Building No. of Persons 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 }C 5 Type of S.A.S. Description of Soil Nature of Repairs orr Alterations(Answer when a plicable) 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 Env' and not to place the system in operation until a Certifi- cate of Compliance has bee ' ued by this TPoard Healt �� 3 ^S Signed qq Date t� Application Approved by 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 9pptication for M 5 ar �p9tem �tCongtrnctton Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. S�G1 S-Irr- �. (Z-1J Owner's Name,Address and Tel.No. Assessor's Map/Parcel \ r` �'C �` L ( I I calle `\r's ame, o Address and Tel.Nr V Designer's Name,Address and Tel.No. lk l Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(A Other Type of Building No.of Persons 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 Z '3 k Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when a plicable) 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 Env' de_and not to place the system in operation until a Certifi- cate of Compliance has bee ' ued by this oard Healt Signed Date �j Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (� Upgraded(� ) Abandoned( )by -� at been constructed in accordance with the pro ' 'ons of Title 5 and the for Disposal System Construction Permit No. dated & Z— 3-- Installer TCO Designer The issuance of this e t shal n b onstrued as a guarantee that the system c ' a gned. Date Inspector Ik , --------------------------------------- No. (' _ (9( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mfi6paar *pgtem Xon.5trurtton Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon V ( ) System located at ivy G1 C) -- S�a, - 2f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this ermit. ^gg s Date: �f 2 3 /� Approved by 1 1/669 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PER1tiIIT (WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated conceriuna the property located at S CA UQe- �5�� (� a'., 1(Aveets all of the fpllowina criteria: • The failed system is canner ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classined as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or chance in use or000sed • There are no variances requested or needed. • Tze bottom of the proposed leaching fadlity will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the m-oundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 3J0 fee;of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the ma.,dmum adjusted groundwater table e!evation, Please complete the followin;: e A) Too of Ground Surface Elevarion(using GIS information) J B) G.W. Elevation =the'vL-LK 'High G.W. Adjustment . to S� _ D11~vREN+CE BETWEEN a,and B SIGNED : DATE: (Sketch proposed plan of system on back-]. a:health Colder-cat Qr- cl�- Commonwealth of Massachusetts �x Title 5 Official Inspection Form R I� Subsurface Sewage Disposal System Form Not for Voluntary Assessments _ f . 599 Old Stage Rd. =. Property Address Michael&Amanda DeFazio Owner Owner's Name. / E information is required for every Centerville V Ma 02632 4-27-2021 t 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. 51�- 15 3�f to Important:When filling out forms A. Inspector Information on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 ,L Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S114324 . Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. X Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins ;Digitally signed by Dan Hawkins •�Date:2021,04.2909:13ao-oa•oo• 4-27-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts - - re Title 5 Official Inspection Form t" - -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owners Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ■❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y '❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - --.............. Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every 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 fall 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 ❑ El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ O Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.00c•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 10 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El 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 '/z day flow ❑ El 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ID 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. ❑ 0 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.] ❑ El 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? E] ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ El 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is'at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 468/GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes rol 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 0 No Seasonaluse? ❑ Yes ❑. No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2020- 21,000gallons 2019- 24,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate t5insp.doc•rev.7/26/2018 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts =ri Title 5 Official Inspection Form ....... ......... to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- last pumped 2019 Was system pumped as part of the inspection? ElYes ANo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ld ,: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: COC 12-06-99 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. 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: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- `lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 411 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank i metal, list s eta, age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 311 Sludge depth: 33" Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1611 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. Recommend cleaning Zabel Filter annually. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts fT a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is required for every Centerville Ma 02632 4-27-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA 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 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every 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): ou Depth of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection. t5insp.cloc•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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is required for every Centerville Ma 02632 4-27-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA *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: 5-infiltrators with stone R leaching chambers number: ❑ 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 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7262018 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 c 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 p Title 5 Official Inspection Form r i8 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately goo k ... ... !: A' t' may' �; !�"� �•z 'kF. .. ;:: s t' t •'. a � �,. a to ' f 3 1 Y £ f F- z t, w�4u'..�w'1.Ma•'�NiatA4i8x ` ^.ras...ww.�, ;.:: - x ,•:' t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c� Commonwealth of Massachusetts r, Title 5 Official Inspection Form ISM p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑■ Surface water ❑■ Check cellar ■❑ Shallow wells NoGW4' SAS Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 11-23-1999 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: A plan on file at the local Board of Health was used to determine high groundwater. 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 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 4-27-2021 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed &Dated and 1, 2, 3, or 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 l9/-005 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments loa. %M 599 Old Stage Rd. I,"t Property Address CIO Michael&Amanda DeFazio x;. Owner Owner's Name information is Centerville Ma 02632 July 24 2018 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. General Information filling out forms 5 $ 3a o on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hicky use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code 508-477-0653 S113747 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑■ Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Brett Hicky ,m - ��w-= 7-24-2018 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17I �0 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 599 Old Stage Rd. Property Address Michael&Amanda DeFazici Owner Owner's Name information is Centerville Ma 02632 Jul 24 2018 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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): l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 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 '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts A w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every 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: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. El El tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to.a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? n ❑ 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? El ❑ 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? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? El 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: E] ❑ 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: 4 3 Number of bedrooms (design): Number of bedrooms(actual): 468/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massach usetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 5 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes © No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No n/a Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes X No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: NA 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 1 year ago 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: El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: COC 12-06-99 Were sewage odors detected when arriving at the site? ❑ Yes ■❑ No Building Sewer(locate on site plan): 1'4" Depth below grade: feet Material of construction: ❑cast iron W 40 PVC ❑ other(explain): >20' 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): 1` Depth below grade: feet Material of construction: ❑E 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 1 Dimensions: 000gallons 1" Sludge depth: t5ins.doc•rev.:6/16 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 ,M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 35" Distance from top of sludge to bottom of outlet tee or baffle 0 Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle Measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection with the liquid level equal with the outlet invert. The tank is not in need of at this time but should be pumped every two years for maintenance Recomend cleaning Zabel Filter annualy. Grease Trap (locate on site plan): NA 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.doc•rev.6/16 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 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA 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.doc-rev.6/16 - 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 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): or, Depth of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection with the liquid level equal to the outlet invert. 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.): NA 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: At time of inspection leaching appeared to be in working order ,with no sign back-up t5ins.doc-rev.6/16 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 5-infiltrator with stone 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working order at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for 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): NA Materials of construction: Dimensions Depth of solids Comments (mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 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 w 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 Jul 24 2018 required for every Y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to. at.least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0■- hand-sketch-in he area below drawing.attached separately rw e' i o- a t5ins.doc rev.6/16. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is required for every Centerville Ma 02632 July 24 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ■❑ Check Slope ❑■ Surface water ❑E Check cellar On Shallow wells No GW 120" 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 0 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: Rear of property drops off over 10' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd. Property Address Michael&Amanda DeFazio Owner Owner's Name information is Centerville Ma 02632 July 24 2018 required for every page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist ❑■ Inspection Summary:A, B, C, D, or E checked p■ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ■0 Sketch of Sewage Disposal System.either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • .� ��•3�I�f �� � �`� � � ��,�,�,,., Mom. .-� CONTRACT Customer Nar DeFazio,Michael&Amanda 01A21��/�' %D Customer Signature xo�/�"�`i U/11411/WX�i�A) Contract Date 599 Old Stage Rd SKETCH Centerville,MA02632 Sales Representative Signature�.���,. ATTACHMENT Customer Phc _. 774-392.4831 Contract Price .30 r 88(0 ,o0 1 2 3 4 5 6 7 a 9 10 11 12 13 14 16 16 17 16 19 20 21 22 23 24 25 26 27 26 29 30 3, 32 33 U 35 W. 37 36 39 40 41 42 43 44 45 46 47 46 49 50 51 52 53 54 55 56 57 56 59 0 . I I I I , 2 m ,_ I I I t I _ I i 16 =122. .L...-_ I .:.. ... .._. -1 `._.�-- -----I -- -4f ) l� t 1. ' I I• _ ' j - I j I I L... 12 I F I ! ,3 i 4, .10 !i Is 17 lll1��� i i I , 21 I I 22 I I 23 e, � f � 24 2e , I I I zr , j I I 29 i I I IIzv '•d' I , 3132 33 35 34 I I j I I I l NOTES: .� L—L��o �- p V&1'7 ),,S , /A U o u 1 uG /v�/ Each box equals one loot unless otherwise noted.This sketch is a good faith J' ( ( representation of the work to be done,it is understood that all dimensions derived from[his sketch are approximate,and that all locations of outlets,light fixtures,plugs,lacks and/or switches are subject to change If necessary. ` 1 L IA PORTANT - UPGRADE REQUIRED STATE 9WLDING CODE REQUIRES THE UPGRADWG of pWID � SMOKE DETECTORS FOR THE ENTIRE DWELLING WHEN 9--77:7 —ILDINu DEPT. DATE ONE OR MORE SLEEPING AREAS ARE ADDED OR CREATED. 7fA L:BU1dOTE: A SEPARATE PERMIT IS-,REQUIRED FOR'THE INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL TME�IT DATE PERRriIT'DOES NOT SATISFY THIS REQUIREMENT. GNATURES ARE REQUIRED FOR PERA4IiTING jj,W,j� q11 1J0�6 ' 1. Install new support header, 3- 12"IVI'S. See engineering specs .............. I �-7Jcco 2. Install new support header, 2 12"Ives. See engineering specs t�1�rn-s o 3. Reframe bathroom walls, existing were 2X3 studs, 24"o% new 2X4 studs 16o% 4&5. Refreme most of second floor, existing 2X3 framing, new to be 2X4, 16o c r ' 9 Smoke detectors=green Carbon detectors=blue h N•114•_ � ` 1 �' %WTI } S1v I\-S Commonwealth of Massachusetts I Ow&I W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville. MA 02632 9-19-12 page_ City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see.completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy "9 } Name of Inspector Upper Cape Septic Services ' Company Name f 29 Atwater Dr : 10 Company Address E. Falmouth MA r � 02536 City/Town State Zip Code::, ° 1-508-495-0905 S13971 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 9-20-12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Q t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of,17 v r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name - information is Centerville MA 02632 9-19-12 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N , ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ,N Title 5 Official Inspection Form . a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7, 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is Centerville MA 02632 9-19-12 required for every ' 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 boz 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: G ❑ 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: I � **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 El ® 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 cloggedP SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded El Z or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 599 Old Stage Rd ' Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® - Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A►copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 3 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 Tide 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 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health an❑ Were system® y of the y tem components pumped out In the previous two weeks. ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components; excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example`. 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is Centerville MA 02632 9-19-12 required for every - page. City/Town State Zip Code Date of Inspection D. System Information Description: ` Number of current residents: 2 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-2012 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 1-2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site?. ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26°feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet - • Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 18" 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: 1000 gal 811 Sludge depth: t5ins-11110 Tide 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 ,M 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 0 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 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley - Owner Owner's Name information is Centerville.. MA 02632 9-19-12 required for every ` page. Cityfrown State Zip Code Date of Inspection D._System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions-, Capacity: gallons Design Flow: gallons per day .Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ,,, , *Attach"copy of current pumping contract (required). Is copy attached? El Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts m s Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is Centerville MA 02632 9-19-12 required for every page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers ,number: 5-infiltrators ❑ 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.): Infiltrator.field in good condition with no sign of back-up into d-box or surrounding stone. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments M 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) t Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form - s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12_- page. Cityfrown - State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t of old l&uC4 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is Centerville MA 02632 9-19-12 required for every ' page. City/Town ' State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I I Commonwealth of Massachusetts T W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 599 Old Stage Rd Property Address Robert Hinckley Owner Owner's Name information is required for every Centerville MA 02632 9-19-12 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 I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSA,CHUSETTS XECTJ'I'IVE OFFICE OF ENWRONmENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM•-NOT FOR VOLUNT ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOkM MENTS PART A CERTIFICATION Property Address:- owner's Name ', Owner's Address: _ .Date of Inspecti ""'--- — Name of inspector` le_.se Company Name Mailing Address• Telephone N P Number* CERTUTCATTON STATE1kIENT I certify that I have personally inspected the Sewagedisposal e fthe system at this address and that the information below is.true,accurate and complete as of the time of the ' specton was reported training and experience is the of o T - performed based on:my approved prrdOII and maintenance of on site sewago disposal systems.I am a DEP FP system inspector pursuant to Section I5.340 of TItIe S(310 CAjk 15.000). The system: ,�_,/_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Alitfiority .Fails Inspector's Sip$tar": hate: The system inspector shall s a copy,of this ' DEP)within 30 daysof co l • mspection report to the Approving Authority �P�flue inspection.If the system is a shared s (Board of Health or Rd or greater,the inspector and the system owner shall submit the report to thetem or a design flow of 10,000 DEP•The original should be sent to the system owner and copies sent to the buyer,a regional office of the authority. pp ' able;and the approving Notes and Comments *his report only descri`tie"s conditions at the time of inspection and under the conditions time.This inspection does not address hog,the system will perform in t of use at that conditions of use. he future under the same or different rr: Pagp2of11 OFFICL41 RVSPECTI( N FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: e J� Owner.: Ta Date of Inspettion:776 Inspection Summary: Check:A B,C;D or.E f ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated: indite ed belo w. in 31Q CMR Comments• r Gt 1_Ct�'f' t1C System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced repaired system,:upon completion of.the replacement or repair,as approved by the Board of H bass . , Answer yes,no or determined(Y,N,ND)-in the for the following statements.If"not rmined" lease explain. p The septic tank is rise d over 20 years old*or the septic tank(whether or not)is structurally. unsound,exhibits substantial ' ation or ex$ltration or tank failure is immin System will pass inspection if the existing tank is replaced with a co g septic tank as approved by the B of Health. *A metal septic tank will pass inspee " if it is structurally sound,not le and if a Certificate of Compliance indicating that the tank is less than 20.ye ald is available. ND explain: Observation of sewage backup `g kup or:break out or hi Ifttic water level in the distribution box due to broken or obstructed pipes)or due to a:broken,settled or unev distr, n box.System will pass inspection if(with approval of Board of Health): broken pi s)are replaced obstruc ' n is removed dis tion box is leveled or replaced ND explain: The system required ing more than 4 times a year due to broken or obstructed pip s).The system will pass inspection.if(with a val of the Board of Health): broken pipe(s)are replaced o struchon Cs removed l 1 ND explain: Page 3 of.l1 N., OFFICIAL"PECTIONTOR44 ' r, l SUBSURFACE.SEWAGE DISPOSAM i► r CERTIFICATION(continued). - Property Address: P Owner: Date of Inspec C. Further Evaluation is Requfred by the Board of Health: dttions exist which require:further evaluation by the Board of Health in order to determine if the stem is failing to Qtect public health,safety or the environment. 1. System"wwi11 pos unless Board of Health determines In accordance with 310 C1VIIt 15303( (b).titat the system:.14 not fu3i oning 1n a manner which will protect public health,safety and the enfironment: (;esypool or:privy thin 50 feet of a surface water rderin 've ted wetland or a salt sh Cesspool or privy is wi SO feet of a bo g i3 / 3 2. System wiil;fail unless the Board of Health(an lic Water upplier,it any)determines that the the c heal safety and enyiron system is functioning In a manner that protects pu _ The system has a septic tank and sod absorption. AS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water s y. . The system has.a septic tank and SAS and AS is within a 1 of a public water supply. and SAS the SAS is within 50 feet of a p ' ate water supply well. The system has a septic tank The system has a septic tank and S .. .and.the S-AS is less than 100 feet but 50 fe. .: more from private venter supply well**.Method d to determine distance **This system passes if the well w er analysis,.performed at a DEP certified laboratory,for co ' bacteria and volatile organic c ands indicates that the well is fret from pollution fmvided that no 0 the presence of ammonia nitro cop the nitrateand nitrogen must b is e etatl to or less than 5 VPM,ta hed to this form. failure criteria are triggered pY _ 4 3. Other: -77777 . .. .... .. . . . .. . Page 4 of I OFFICIAL INSPECTION FORM:—NOT FOR VOLUNTARY ASSES$b4IEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: e Owner. Date of Inspection: t S`t�; D. S-ystem Fo um.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 corripoaent 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 j Static liquid level in the distribution box alcove outlet invert due to an overloaded or clogged SAS or c.?—pool L/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'A day flow tTf Required pumping.more than 4 times-in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped I / Any,portion of.the SAS,cesspool or privy is below high ground water elevation. Any.portion of cesspool or privy is. 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 coliform bacteria and volatile organic compounds Indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less.than S.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this foruLl f (Yes/No)The system falls.I have determined that one or more of the above failure criteria exist as described in 316 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health toZetermine what will be necessary to correct the failure. E. Large Systems: To,be nsidered a large system the system must serve a facility with a design flour of 10,000 gpd to 15,000 gpd: You must cate either"yes"or"no"to each of the following: (The following feria apply to large systems in addition to the criteria above) yes no the system is wi 00 feet of a surface drinking water supply _ — the system is within 200 fee tributary to a surf g water supply. _ the system is located in a nitrogen s area_(h--* im.WcUhead..P-rotcctionArea—IWFA)-or a peed-- -- Zorie11-ofapii.51 water well If you have answered"yes" any question in Section E the system is considered a significant threat,or answered "yes"in Section D abo the large system has failed.The owner or operator of any large system considered a significant threat un 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. =Page 5 of I .> -Mr .. Ol ' L INSPECTION FORM IY FOR VOLII TTA t AS ' SSN EI FCIA OT S -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTWN t& PART B CHECKLIST Property Address- 7i - qq,,r``Ile— Owner: 1 , = r Date of Itspect(u ► Check ifthe following have been done:.You must indicate.-- yes"or"no"as to each of the following: Y No _ Pumping information was provided by the owner;occupant,or Board of Health Were any of the system connponents 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? I' Was.the site inspected:for signs of break out? _ Were all system components,exchuling 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 m proper ainten_ance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y no Existing information For example,a plan:at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is.unacceptable) (310 CMR 15.302(3)(b)] n Page;6 of: .1 OFFICIAL INSPECTION FOCI NOYfO4t-. ....TAR?ASSESSMENTS SIMSURFACE-SEWAGE:DISPOSAL SYSTEM INSPECTION 'UItM PART.C. SYSTEM INFORMATION Property Additsa .q 9 0 1 f) S-4-rg c f Owner: ` Date of Inspec onp. FLOW CONDITIONS RESIDENTIAL Number ofbedrooms(design): Number of bedrooms(actual): DESIGN flow based oa 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have 4-garbage grinder(yes or no):�Q Is laundry on a separate sewage system(yes or no)4LD(if yes separate inspection required] haundry systern meted"(yes or no) p Seasonal use:(yes or Ao),: Q Water meter readings,if available(last 2 years usage(gpd)): 4 Sump pump(yes or no) 1A Q _ Last-Elate of occupancy._ t COMMERCIALANDUSTRIAL i ype of establishment. Design flow ' on 310 CNM 15.203): avd Basis of design fli�w / ersons/sgf;etc.): en�ease trap present(yes or no ._ Indnstial waste.holding tank present:..(yes or no . Non-sanitaty waste discharged to the system(yes or no):_ -- Water meter readings,if avail Last date of occupanc OTHER(desen"be}: GENERAL INF01MATION Punping Records Source of information: A �l v C`� C eC%r-"L.YJ Was system pumped as part of the.inspection(yes Sr no).y. If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping. E OF SYSTEM Septic tank,distnbution box,soil absorption system cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _T Ynnovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank ^Attach a copy of the DEP approval tfier(describe): Approximate age of all components,date,ins ed(if known)and souce of information: 1 Were sewage odors detected when arriving at the site(yes or no):0__Q Page 7 of 11 j' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUlBST7RF'AC]E SEWAGE ]DISPOSAL S'YS'TEM INSPECTION FOR�VI PART C SYSTEM INFORMATION(continued) Property...Address: Owner. Date of Inspecliou BU LIDING SE`M(locate on site plan) `f Depth below grade;at Materials of construction: cast iron J40 PVC_other(explain): Distance from private water supply well or suction line: v1 Comments(on condi"on of joints venting;evidence of leakage,etc.): P Q SEPTIC TANK:.—(locate on site plan) tr Depth below grade:. ILIA . Material of construction: concrete_metal fiberglass_polyethylene other(explain) If tank is metal list age:T Is age confirmed by a Certificate of Compliance(yes or n®):_(attach a copy of certificate) t T Dimensions: gE.dep Distance from top of s ud a t6lottom of outlet tee or baffle. ` Distance from top.of scum to top of outlet tee or baffle: ' �7 << V d C'��\ Distance from.bottom of sewn to bottom of outlet tee baffle: — C How were dimensions determined: �e Comments(on pumping rccomn=ndati&w inlet and outlet tee or bsffie condition,structural integrity,liquid levels as related to outlet invert evidence.of leakage,etc.): GREASE TRAP: (locate on site plan) Depth belo ode•_ Ivlaterial of cans _concrete_metal fiberglass_—polyethylene otter (explain): — Dimensions: Scum Dimensions: Distance from to to top of outlet tee or baffie: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ .P.YxA.6 .PCB x.P�L .P.>xAd .PAD x,P�6 V h A Y b I e � h b N A s a n o O TOWN OF BARNNSSTABLE LOCATION «.� V ��`'i SEWAGE # VILLAGE L'� �:� `k e- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CX �1 /&'L)C' T- LL LEACHING FACILITY: (type) 1��� (size) 1 NO. OF BEDROOMS BUILDER OR OWNER ' `" H l^ PERMITDATE:�� � .'3 l�� COMPLIANCE DATE: IA&LI/11 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) �•v;� Feet Furnished by V A a 1 ¢- �� - -• -------erg 5------ --- - - - Or (T-L1'! -d!-. .GAF. a' _T� gta�.C.�.yrD y--o Z2c £� T'��T. •�. , • tA _.7 off,,, DO M - � BZ 2 1x� P 3�n f G 5 c, tom+ r14 !itT a J7*/ y _ SCAtE: 4 = I_ D` 'APPROVED BY: DRAWN BY �q��� . DATE: C7 S-U I HydY11115,MA DRAWING-NUMBER i 3 BA.RRY JONES=HENRY DESI6NER