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Home My WebLink About0740 OLD STAGE ROAD - Health 740 Old Stage Road Centerville P A = 191 114 aMpSe/fib 1521/3 ORA 100,0 P2 TOWN OF BARNSTABLE r Cp LOCATION 7 V� / e/ SEWAGE # 01 7- 7 Z i VILLAGE— fil/ L ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrTY: (type) r� (size) L NO. OF BEDROOMS BUILDER OR OWNER 1 1� e PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells existon site'or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ' ---------Feet Furnished by r r�r TOWN OF BARhISTABLE \ Li ON''I C/ SEWAGE # r VILLAGE— ASSESSOR'S MAP & LOT II II LER'S NAME&PHONE NO. Sl .TANK CAPACITY FACILITY: (type) E,i�r� (size) �''7 X 2< N »bPtEDROOMS i�,��""I R OR OWNER 1 J q ' DATE: �-- t 1 COMPLIANCE DATE: Piv T._ Seaiatican Distance Between the: Mimum Adjusted Groundwater Table and Bottom of Leaching Facility l Feet I? yatt Water Supply Well and Leaching Facility (If any wells exist r— Q#.Aite or within 200 feet of leaching facility) eet >✓de'of Wetland and Leaching Facility(If any wetlands exist :;.w tf i�n 300 feet of leaching facility) -"-Feet FuWshed by `�` ,,• ,.tilt TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 1 D/,laximum 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 Edgy of Wetland and Leaching Facility(If any wetlands exist .within 300 feet of leaching facility) Feet Furnised by11 1_ _ _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ca 740 Old Stage Road Property Address W.Kurker Owner Owner's Name 4? information is required for every Centerville l/ MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection W 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 f filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. R.L.C, kCompany Name PO Box 726 Company Address South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 St 4590 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 / /Z /ey 10q01& Inspe 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 _ U 1 , Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: At time of inspection septic tank and distribution box were observed with no failures. Tank was pumped as part of inspection and riser put on distribution box and center cover of septic tank. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 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 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins-3113 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 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: At time of inspection the property was unoccupied . Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015=90 GPD g ( y g (gpd))" 2014=173 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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-3113 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 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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: pumped in 2005 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump truck Reason for pumping: Remove solids and inspected interior of tank Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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: Tank 1977 distribution box and leacxh field 12/19/1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): interior sewage ejection pump is not sealed properly ,no indications of back up observed. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Septic tank had PVC tee and gas baffle on outlet only visable when pumped If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x5x5 Sludge depth: 12 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3Vey'� 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 2" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was at operating level at time of inspection and no indication of high water stains. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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): Depth below grader Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection 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 M 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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 equal to both outlets Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box had no stain lines above outlet inverts and no evidence of carry over observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 34'x2'x2.5' perf.PVC 2 legs ❑ 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.): Soils above leach field were dry with no effluent staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs'of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Re4 r of V 7yO old 6117e- ed' C A � � - as cot 3 � I - ay' :2- 3= ) 9) Ll= 62J' C430 '`II t5ins•3/13 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 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 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: 14.8 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: 12/19/1997 Permit Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: permit and COC on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Permit and COC on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 740 Old Stage Road Property Address W.Kurker Owner Owner's Name information is required for every Centerville MA 02632 10/04/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MAssAcHUSETTS EXECUTNE OFFICE OF ENVIRONMENTAL A.FFAIRS I�EPART7 T ®E NVUtO l`1TAlG PROTECTION R CL""r� MAY 1 0 2005 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 3 ,IDCgAi,INSPECTION FORM—NOT FOR VSALjARy SYSTEMSN'I'S SI1I3SU]�AfrE"WAGEPART A PO FORM CER CATION 41 ` � 1 property*Address: f Owner's Name: owner's Address: � Mate of InspeC60n: N-M of Inspector: ('please rint)t Compwy Namne. Na7ing Address: e Telephom Number: caoS CERTMCATION STATEMENT that I have persanslly inspected the sewage disposal system at this address and that the information reported l°� complete as of the time of the inspection.The inspection was performed based on my - below #ue�accurate and d mair+tenanc� o bite sewage dispose!systems.I am s IDEt? approved� pector pnrmont to Section 15.348:of Intle (31 o cis rooa _. system Passes Conditionally Passes Needs Further Evaluation by the Local Approvi g Authority _ F6 Date: "toes SignattuM% of this inspection report to the Approving Authoity(Board of Health or Ibe men inspector shall submit a copy ion.If the system is a shared system or has a design flow of 10,000 DEP)within 30.days of completing this inspect or greater,the inspector and the system owner she!l submit the report to the appropriate regional office of the gpd DER 7he OH&81 should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments deserib"conditions at the time of inspection and under the conditions of use at that ****This time- This report only perform in the feature candler the same or different tine.`f'h�hasiPe�°'m does not address how the systems e++iU conditions Of arse. page 2 of 1 I OMCIAL MspWnON FORM—NOT I'OR'VOLUNTARY ASSESPMNTF, SDBSURFACR STWAGE DM A SY iN8 n0 N FORM tC tTI�'dCA ON (contim ied) arty Addrem r s Date of inspection Snmmmry. CWk A,B,C,D or E/ WA complete all at Section D A. System Passes: 4I have not f0t any it on whub indicates that any of the f knwv criteria dear 'bed 314 CMR 03 or in 310 CIvM 13304 exist AnY Sara ccita"L not cvabuated are kWicebod below. Comtaxnts: B System ConditionallY Fasces h l n t Bye, ponents as described in the"Conditional Pass"section need to be replaced or one � ee M&C uponcompletion of the replacement or repair,as approved by the Board of Health,wM pass. Y Answer yes,no or not ddammed(y N ND)in the for the following atataa uft if"hot deWmined"please explain. i y�, ,tel -2A 01&*air the s tank(whetlW metal or not)is shucda ally . mfiltraiion a =or - ----_ MMi ICUL e exhibita �. tank is irephoed with a camplyang o t�as by the Board of Heahh. *xrstmB tank will pass m if it is dMcb aUy sand,not laditg od if a Certificate of Compliance A meal old is available. indicating t>tst the tank is less than 20 years ND eacpinin: _ obwvation of sewage badcup or Mt Of high static water level in the distrr`btation boa due to broken or obstructed pipe(s)or due to a broken,settled Or mom d*&Aon boat.System Will pass won if(with approval of Board of Health). ixoken pipe(s) dism'Won box is leveled or rephwed ND explain' 'the system required pumping more then 4 times a year due to broken or obstructed pipe(s).The system will ;;j ispection if(-WIh OV81 of the Board of Healihx broken pipe(s)are replaced ob ucdoo isrmoved ND explain: page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOL MARY SS SMI S SUBSURFACE SEWAGF DID CER CORM PAW A ATION(contia>ICO pro"rty Addtem < Y Owner: . Date of Ism C. Farther Evslnntiea b ftgtdred by the Board Gf Health: Allelley re4M further aguatwn by the Bard of Health in order to detsnnine if the system m om exist soft at the envk oomem is�iliagw Plied p� ,so Mess Beard of Aealtb d in accw amwith 310 C�1530 0)(b)that the I. System will pass in a ataatter wbkb WE proms pabtta he ^a"and the eavironmeilt•. system is MA 1� Cal or Privy is within 50 that of a sulface water wetland or a salt marsfi spool or laivy is within 50 that of a bordeft vegetaftd(�PuM Water ,ifs")d0eraftes th the 2 �mPo�d auka ma �photeels the�hesW sett a°d enviuratmeat: s> and the SAS is within 100 of a The sydm has a septic teak and sot"abaor0(G system(SAS) vista supply or tYitiutwy to a siafaoe water ----- -- - -- 0 is wi>ltia a-?one 1 - a public wa - of t+e+r supply. The system _ _ --- - - water supply welt. • system Las a septic tank and SAS and rhea sAS is within 50 feet of a Ovate . he has a septic used took and SAS and the SASS 100 feet but 50 feet or mom from a private water supply well*s,MAW to deoarmune at a DEP certified labormoty,lot colif in **Wm�M passes if the well water nIc compounds �weU is free froma pollmim from drat be ty and bofammnknkeom mtreteamd nitrogen is eqW to or less don 5 ppak PMvided tlmt no odd fidhtro �grgc&A c*Y of dte Maly,&must be am&cd to this farm. 3. Other: M page 4 of 1 I OFFICIAL INSPECTION FOBM—NOT FOR VOLUNTARY ASSESSIM W DSUMACE SWAGE DMUgSATM SYS-r INSPECTION FORM P CERTMCATION(continued) property Address: 7-0 owner: Date of Q Criteria app =1e to all systems: You magi indicate`Y "Or'tW'to each the following b Om Yes BadMP of sewage into fatuity w system component due to overloaded Orclogged SAS or cesspool DWbBW of po ft of effluentto the sudbW ofthe ground or swats waters due to an overloaded or doWd SAS ar bo avert ot above Odd due to su over�ded or clogged SAS or Stalls liquid level b the 'DOM cesspool m is lea am C'below h Mt or avaflable volume is less than%day flowNumber liquid Opipg snore than 4 times in the last yea M dee to or obstructed pied Any pmtiaa of*a SAS,CWWOOI ar pft is below bigb Wound varier elevation. (� A.Y partian cf or pnvY is WWdD 100 fed of a surface wdw supply ar Y to a surfaee `"mom supply- t a pdvY wilder a zone i of a public vaell. v Any of aoeaWd or PiTy s W"SO ifod of a private valor ly water f � �p ofa (or privy is lets tLen 100 to but greacty then 50 gtie well vraler' aooep�`"A''er�'9o"Il'ae`lT1ds>�1� aei vddb O "Now-_ - asDLlmt WisaEmerao - - -_-- € hwee"M add*WA bkoffm �aiLrale �o��err!�t1u s��flat Resew t�re:rlteria are d�et�A copg►�1Me nod Le attar �• u�l Y Lavecone ar JUMlb contadthe Board of is31ACMR15.3g, U d wbetw3benecesmytoco 'C190 fiftt Heaifliib L IUP Sydemas tLo wed i"ce a hdft with a ddP flow of 10,000 gpd to IS'M To he oo • U& ei*W or-W to Mtoftheynlloa►i* YOU Most I**to large system m addidw to the crueria above) yes no the system is within 400 fed of a suufaee dfWdug water supply _ Me system is within 200 fleet of a U&dM to a snrtae drinking wad SUWY is located in a nilrogS sensitive area(Iderim WdM ead Protection Area-1WPA)or a mapped zone II of a public water supply well , •to y� question in Section E the system is considered a signiticad threak or answered Myou have ,Tlie owner or operator of anlr large system oonsiderod a .yet'in Section D above the large or idled D" tlm in scoordaoe vuith 310 CUR fo r Section BCoutea o ap Section office of the Department- 15.304.110 system owae1 s>tonld OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B KLiST Property Address: Owner: cry es c�/ Hate of L�eectloe: Check g•tLe&ftw :mA have been done.Yon want indicate "or`Sw"as to exh of the t'ollowi�a Yes _ Pmmping infomoadm was Provided by the owner,owipant;or Board of Health -,x Wefe ant►of the system oonoipmems pumped oat in the pre♦ions two weeks? IV- Has the system received nomeat flows in the previous two week period? — Have largevehiuees of water been introduced to the system reoentiy or as part of this kqx lion 7 — Wem as buik plus of the sydem obtained anti eem m a(Yf tteey were am avai'table 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 aU system Component%mbdmg ft SAS.located on sine? .__. Were the septic tank Wiles nnawewd,opened,and the interior of inspected the-cohhditia� -� - = tlroflfqui "Ph(f s 00 arnl depth of scam? _ was"try owner(and coaopants if different from owner)provided with itifiormation on the proper maintename of sttbsuraace sme►age Ssposat syws? The dae and toaedon of the Sell Absorption Systm(SAS)on the site has been determined based on: no _ mdsung wrm gmL Boar example,a play at eeBoard of Health. Del ermined into field(if any of the f eve caiteda related to Part C is at issue aAroxinne6on of distance is unacceptable)[310 CMR 15302(3)(b)j I page 6 of 11 FORMrNOT FOR VOLUNTARY ASSESSMENTS OFFICIAL INSPECTIOND INSPF�'."rjON FORM - S�TBSURFACE$EWA PART C SYSTEM INFORMATION Addi"S 7 DateOf '°�'� Ft ow corrnrrfOrD MSIPZNUf L bedrooms(ACMW Numb=Otb ( p r 15.203(t ---Ple: 110&Ax#ofbedmaoIO DESIGN goo►based OR ofcam� � regnirrd] bsve aVabap or s no):24.4 Of y" i° o" y on a e or no).A LaundiY�'� iveg geasoial>W-0 Or no): (A 2 yeas usMF(tom): wato:mom readings,if . sun*PM(Yes,arno). last daft cf COWUWaCLUND-USTRML 'type o[ �,310 l�1s.203x De li r► BasiSd ( e tiap (9e8 or nor..� Watetnoet� if availabld� Last date01 - -- OTI3EB O' �OgMATION GENERAL Pon4ft Re"r& :., �inn $011rt��.. P� Part O tine�..a1"^"""W �QO�: 1 . � I��TG1 8S q 1Nyo Volume � (ldxts— 2 ncJ cum ��S Reason Pum for POWN's- Olf dim boot,soil ab WPdm Systein single cessPoo1 `(3vatow cesspool ton records,if u►y) sYSte1°(YW or.Ot�yes,attwb P'�a"ems o t �ioa�and mainteasnc�c�nntcact(to be InnovatirdAl�Da1"fe o�ght Stank Atted+)a COPY of*.DV appr�ether(desanbe): age co9np�ea� � ed(if kno )and source of information: a of all 1 a odors detected when arriving at the site(yes or no): Were sews 8 Page 7 of 11 OFFICIAL INWFkTION FORM—NOT FOR VOLUNTARY ASSE3SMENU SUBSURFACK SEWAGE DISPOSAL SYSTEM RUPF,CnON-V?RM 2'ART C SYSTEM RMATION(continued) Pn*wi't9 Address:*CIAIM�j4E� �. oworr. T-' Date of iaepodbn: O BUILDING SEWER(1 jh=m lan) Depthbelow raftMaterial ofcon�raebon: 40 PVC o diter(explaix Distance from private vvaw supply well or suction line: Comments(on coatdition ofjoints,venting,evidence of leakage,etc,); SEPTIC TANK: on ske plat) Depth below grade: Material ofconstruc6on: Crete `metal fiberglaes_polyethyleae other(explain) If tank is metal list age Is age confirmed by a Certificate of Compliance(yes or no): (Attach a) Dopy of Sludge dq&. o l i Distance font top of A*v to bottom of outlet tea or beffia _ Scum tWdmew-. /,A" - - --- Dis�anae-fi�o�n_to�ofsa�_tQtgzQ£o t�or lmffi�� . Distance Snom�bottom saw a orbe: How mm dma detemoined:_�'T�cC�� :99RI2_ a Commeata(on pmnp4 reoommendation4 inlet and outlet tee or baffle condition,sdvctural `related to " vertu evidence of leakage,eta 1 l` �tY�liquid levels eF�n � t- e GREASE TRAP:/ an Site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene odner Dimension - Scum thickness Distance from top of Banat to toP of outlet tee or baffle: Distance ft m bottom ofscut to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recomme cos,inlet and outlet tee or baffle condition,structural Wegdty,liquid levels as related to outlet i§V^Cvidanoe of teaksm eta): page 8 of I I OFFICIAL INSFEMON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUIItFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MORMATION(continued) property Address: �Svj Owner: T � Date OrLr'q moos: l TIGHT or HOLDING T � must be pumped at time of inspedionxlocate on site plan) Depth bdow grade~ Material afooaanuoxion: +oonctete metal fibe�6lass.�.polYetbylene other(explain): Dimensions• — capachr Gallons gn gym„. Rallaas/day Alarm present(yes ar nor Alarm lc-vd- Almm in vAxWeg order(yes cr no): Date of last pumping: Comments(condition ofabrm and float switches,etc): DETM TTION BOMX Of prftmt Must be openedxlowte an site plan) Depth of liquid level above outlet invert:„ Cmaunts(note if box is level and distribmdon to outlets equal,any evidence of solids carryover,any evidence of - 1 �mr or- tJ I r'� etTn t A D Q v C p W CIIATV=ER;/V Ocaie an site plan) pump in workh*order(yes or no): Alarms in wonting order(yes or IIO): Comments(note Condition of pump chamber,condition of pumps and appurtenances,etc.): ' page 9 of I 1 . OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSIM EIS TS SUBSURFACE SEWAGE DIISMSAL SYSTEM INSMAL ION FORM PART C SYSTEM ORMATION(continued) rmperty Address: Q o�►ner: Ir Date efuspecam. SUIT.Ag`q RMON SUM(SAS)*- te on she plan,excavation not required) If SAS not located Win why: bxej, orA-t e 4 e `r c1r�K ype leaching pits,number:,•_ leading embers,number. leaching gailades,number: leadng$dds�mwiber,dimensiow number: innaimthwaftanative sY ° 'name of technology: Comments(note con"ou ofsog,sips•ofhydmulia faflure level ofponding,damp-soi),condition of vegetation, a a a CES MOMI of must be pumped as part of impoction)(1mte on site plan) Number sad cc 5998f top of liquid to inlet invelt: Depth of solids 18yet: Depth of scum layer: Dimensions ofcesspool: Materials of conggndim Indication of Wmadwater inflow(yes or nod Cats(now c oadMon,of soil,siPs of hydraulic Mum lad of ponding,condition of vegetation,etc.): PRIVY A (locate on site plan) Materials of eonsbucti n Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic fa lure,level of ponding,condition of vegetation,etc.): gage 10 of NOT FOR VOLUNTARY ASr�SISMEEN'rS • ON FORM_ lNS>PECTION FORM- OngMACE SEWSEWAGE DLSP'OAL PART SYSTEM 1NFORMAIION(oontinued) 0000 Property Address �/ owner: t of Date of SK>�" SEWAGE D om'SYS"I�Iluding ties to at least two pmasnent reference landmarks or a*etch of the so" Ob�Whom pubhe water supply enterse bu thilding. Locaw an Wdb wit bl r Vac,\� FRI t 3-3- 3< < P I� ��. � ftge l l of I, INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS OFnCIAL SUBSURFACE SELVAGE DISPOSAL SYSTEM IlVSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: OwneEf m Date I °n= SITE EXAM Slope sur6 a water Check cellsr Shallow wells 144 EstdW&to gmund water ► fey es Please indicate(chock)all methods used to determine theWah ground water elevation: P r000rd-1f checked,date of design plan reviewed: 1% Obtam�from /ovation hole within 150 feet of SAS) observed site(abuRtm Chocked with 1ocs1 doc umemwon) —Chod ed�� abase-eocplain � Accessed W the water " y �nngz descxa�how•you .5 .'Ip No. t'9. 7 (((fff Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mie;pogal *pgtem Construction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lo No O er's Name,Address and Tel.No. -7 Y 0 o/2 c Assessor's Map arced � a Installer's Name,Address,and Tel.No. Designer's Name,Ad ress and Tel.No. �J /W C,- . U �v Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 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 Type of S.A.S. Description of Soil Nature of Repairs or Alter do s(Answer when applicable) 02 Jv, (✓ Date last inspected: Agreement: The undersigned agrees to en construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 o e Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo d of ealth. Signed G� Date Z Z_,W f'7 Application Approved by Dater' Application Disapproved for the following reasons Permit No. "` Date Issued rt -No. Fee ' ! X... THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN O•F BARNSTABLE, MASSACHUSETTS Application for Mitpotal *pgtem Conttructiatt- ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Y e)Address or t oy Owner's Address^ Tel.No. t Assesso larcel � C yLf1L InstallTer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L) 3 v Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 3 e Design Flow gallons per day. Calculated daily flow gallons. . Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ` Description of Soil J;- Nature of Rep'or Alter do s(Answei when applicaa6le) Date last inspected:,. _ A reement:''"'—/ The undersigned agrees to en ure-t construction and maintenance of the afore described on-site sewage.disposal system in accordance with the provisions o Title 5 o he Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo Vf ealth. Signed � .. Date /2-&—,P,7 Application Approved by .. Date Application Disapproved for the following reasons r f: Permit No. 9 - Date Issued -------------------- --------------THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (41 Upgraded( ) Abandoned( )by _T10 Mil at 7.1,0 has been constructed in accordance with the provision of Title 5 and the for isposal System Construction Permit No. w dated j Installer ,:...- Designer The issuance of this vermit shall not be construed as a guarantee that +t the syst Ill fui� designed. Date 1 c7` Inspector_r -----ty----------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mitpo!ar 6pgtem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Aba don( ) System located at �w 6 �A /1. 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 t. j Date: �. ` /" Approved b �-�' 2-�L��.� l/ �=�"`'"�l 10/9197 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 PERMIT (WITIIOUT < ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �if concerning the meets all of the property,located at following criteria: • There are no wetlands located within wo feet of the proposed leaching facility (,. There are no private wells within 150 feet of the proposed septic system �e There is no increase in now and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will D91 be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Gr ound Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) • G�SIGNED: DATE: LICENSED SE IC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan. this plan should be submitted). q:health folder:cert G�� TOWN O>`BARNSTABLE 5. L(7 'I' ON D C/ ✓ SEWAGE# �.7- 7 Z :::• -- ASSESSOR'S MAP & LOT VILLAGE � II49TALLER'S NAME&PHONE NO. .. SEl''TI .TANK CAPACITY I,E;AC)`T[NG FACII:.ITY: (type) (size) Nth»;OF•BEDROOMS t BUILDER OR OWNER S G e q PEEtIvI'TDATE: �—� — `1 COMPLIANCE DATE: Separation Distance Between the: Mcunum Adjusted Groundwater Table and Bottom of Leaching Facility Feet J Private';�Vater Supply Well and Leaching Facility (If any wells exist i-- ; on site or within 200 feet of leaching facility) "Feet Ed#e::of;Wetland and Leaching Facility(If any wetlands exist - Feet <:;wflii'n 300 feet of leaching facility) )&unshed by I� aL 1 71( L( z Jq . ?,, S CO`NON%�_EALTH OF MASS.ACHL'SETTS x ^] _ EXECUTIVE OFFICE OF EN�tiIRONMEN. AFFAIRS DEPARTMENT OF ENWIRONNIENTAL PROTECTION fit= y N 1•tA 02106 F1-.:s..�4, w ONE WINTER STREET. BOSTO 9 . ,y 4199 7 t Pj f U-ILLIAM F.MILD \ TRUD`i C& Govclnc Gi Se:'c- ARGEO PALL CELLL"CCJ - . _w:,= DAVID B S i I - Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissi'. PART A - CERTIFICATION Property Address; ,q.o did 5t�t �y� 1 1 ddress of Owner: Date of Inspection: �� , 1�1 =-Of different) = Name of Inspector: {J'�4�� I am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMRT.000) Company Name:�-/ o�,-�,'c Eir P-,,o_�+� we P.A 4�lOWL Mailing Address: �ep l3 o,c -,c Z, 4 q Telephone Number: _5-G Zv = _. CERTIFICATION STATEMENT 1 certit that I have pe•sonalh inspected the sewage d!sposal systeci at this address and that the information reported beioN is true. accurate and comolete a-- of the time of inspec,,o-. The inspez;on was performed baser on my training and experience to the proper.function and maintenance of on-site sewage disposa: systems. The ns;err: _ Pastes - _ Concioonai;% Passes _ tieec; Furthe- E,.•a!uat:on Sy the Local Approving Authority Fa S Inspector's Signature: 'Date: T;,e Svste-r Insrecto• sha" s_bma, a coPy of this inspecoon report to the Approving Authorin- within thirty, (301 days of completing this inspeGion. It the s\-stern is a shared ss•stem c, ha; a des,gn flow of 10,000 gpd or greater, the inspector and the system owner shall subm : the repo-, tc the appropriate revoral once of the Department of Envtronmenta Protection. The orig:na! should be sent to the system eN.n,e and copies :-n;to the buyer, if applicable, and the approving authority. - INSPECTION SUMMARY: Check A, B, C, or D: Aj SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure citeria as defined' in 310 CMR 15.3Q3 Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system, components as described in the 'Conditional Pass' Section need to be replaced or repaired. The system, u�= completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system insaecor with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or ta-. failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (--evIs•d 04/25!97) Page 1 of 10 CERTIFICATION (continued) Property Addcass: Owner: _ _ `�; i:i b-.1 _ =T Date of Inspection: Bl SYSTEM CONDITIONALLY PASSES (contin,,id _ Sewage backup or breakout or high static water level observed in the distribution box is due t broken or obstructed pipes) or due to a broken, se*led or uneven distribution box. The system will pass inspecti if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed _: distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstruct pipe's). The system will pass fHealth): - - - - - inspection it (with approval of the Board o _ .. broken pipets; are replaces obstructior is removed .1- -w CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:�.M Conditions exist which require further evaluation by the Board of Health in order o determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE YSTE.M 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE E. IRONMENT. Cesspool or pm-, is within 50 fee: of a surface water Cesspoo? or privy is within 50 feet of a bordering vegetated w ,land or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PURL WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONINC IN A MANNER THAT PROTECT HE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption syst (S135 and the SAS is within 100 fee: to a surface water supply c tributan• to a surface water supoty. The system has a septic tank and soil absorption s tem and the SAS is within a Zone I of a public water supoty well. The system has a septic tank and soil absorption ystem and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorptio system and the SAS is less thar. 100 feet but 50 feet or more from a private water supply well, uniess a well water nalysis for coliform bacteria and volatile organic compounds indicates tl-z the well is free from pollution from that faci ty and the presence of ammonia nitrogen and nitrate nitrogen is equal to cr less than 5 ppm. Method used to determi distance (approximation not valid). 3) _ OTHER (revised 04!25,3-) Page 2 of 10 Y " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Ad'd-ross: l� Owner: ` k V Date of Inspection: D] SYSTEM FAILS: You must indicate ether "Yes- or 'No` as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 13.303 T ne tars for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correc the failure. , Y,es .� Backup of sewage into facility or system component due to an 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 clogge-d S.A6 a- cesspool. Sta:ilc liquid level in the distrib:,tion boa above outlet invert due to an overloaded or clogged SAS or cesspoo;. Liquid depth in cesspool is less than 6" below invert or availabie volume is less than 1/2 day fiov. Recui►ed pumping more than 4 times in the last year NOT due to clogged or obstructer pipes . Number o'times pumped Am porno^ o`the Soil Absorption Svsterr,, cesspool or pricy is below the high groundw-a:e• eievanon Am por:on of a cesspool or privy is wither. 100 feet of a surface water suppiy or tributary to a surface water supply. Any porion of a cesspoo' or pr,a is withm. a Zone I of a public well. Any pc-ocn cf a cesspoo! or prnti is within 50 feet of a private water supply well Am par-orr o-a cesspool or prj\1• is less than 100 feet but greater than 50 feet from a pnva:e water supply we!i with nc acce:tabie Ovate, qualitt a-a!ysis- If the w•e!I has been analyzed to be acceptable, araci c:c%- eT we!I water anaMis fey coliformi bacteria, volatile organic cor-;pounds, ammonia nitrogen and nitrate nrtrozen. E] LARGE SYSTEM FAILS: l ou must md;cte e::ne• "Yes` or "tio" as to each of the following: The fo.iow;rg criteria 2PP;v to large stKtems in addition to the criteria above: The p.-stern serves a facility with a design flow of 10,000 gpd or greater (Large System; and the pvs:e- is a significant threw: to pu' iic health and safe:} and the environment because one or more of the following conditions ezls:: 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 systern is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWFA) or a mapped Zone ll of a public water supply well) The owner or operator of an), such system shall bring the system and facility into full compliance with the grcundwater treatment program requirements o, 314 Ch1R 5.00 and 6.00. Please consult the local regional office of the Department for furier information. (rsv4.sed 0/.".S/97) Paq■ 3 0: 10 PARI B Property Address: Owner: J Date of Inspection:, Check if the following have been done: You must indicate either 'Yes` or'No`as to each of thYes e following: —A No :-. - Pumping information was provided by the owner, occupant, or Board of Health. _ gone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -_ As bull' plans have been obtained and examined. Note if they are not available with N/A. The facdi;x or dovelimg was inspected fo, signs o-sewage back-up. Tne s,%•stem does not receive non-sanitary or industrial waste flow. = X — The site %%as inspected for signs of'breakout. . *C _ A!I components. excluding the So!! Absorption System, have been located on the site. _ The sep:,c tank manholes µere uncovere+. opened. and the interior of the septic tank was inspected for condition of ba-ies or tees. materia' o-construction, dimensions, deptn of liquid, depth of sludge, depth of scum. The size a-ld loca:.on of the Soil Absorption System on the site has been determined based on: — The facia\ o,..ne• iane occupants. if difreren: from oµ•neri were provided with infomation on the proper m a aintenance Sub-Surface D-sposal System. Existing information. Ex. Plan.at B.O.H_ V — De-erm-ned in the field td am of the failure criteria related to Par, C is at issue, approximation of distance is ]� unacceo:able 1t3.302:3;:' l (revised 04/25/571 Page 4 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertN Address: Owner: V J Date of IHspection:�I FLOW CONDITION'S RESIDENTIAL: Design t1ov,W - e-P.cllbedroom for S.A.S Number of bedrooms , Number o�current residents- Garbage g•;:der (yes or'no!:-Li Laundry co--'^ected to syste (yes or no! Seasonal use Ives or no,: Water meter readings, if available (last two c2i Year,usaee tgod,: -1j Sump Pump lees or nod Lai:date of occupancy D�MG COMMERC?AUINDUSTRIAL- Type of establishment. Design ffo.. ! - - g _ga ionvaa. Grease trap present. Ives or no_ Industrial %%aste Holding Tani; oresent. Ives or no :on-sancta- -Aaste discharged to the Taie 5 system. ayes or no eater meter readings- if availabie Las:Fate of o c::Ya-c. OTHER: .De:crfbe Last sate of occucanc. GENER4l I.NFORMATIO.N PUMPING RECORDS and source f fnformatf , ev System pumped as par, of inspeGion: tye5 or no If yes, volume pumped ¢allons _ Reason for purnpmF - TYPE OF SYSTEM Septic tankrdistributfon box!soil absorption system Single cesspool Overflow cesspool Pri.)' Shared systern (yes or no) (if yes, attach previous inspe-iion records, if any) - VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or notes (ravia.d 01/25/9�) Daga 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTE!-1 INFORMATION (continued) Property Address: 0 , Owner: W F Y" Date of I6pection: BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explain!. - Distance from private water supply well or suction Ire Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANKS (locate on site pI ^� Depth below grade Material o;construction: -\concre*.e mesa Fioergiass Poivethvlene _othertexplain If tank is me:al• Its: age _ Is age con.firmec b\ Ce-;:fica:e o; Compliance _(1'e5.-No Dimensions U0 - -. Sludge depth -- - Disidnce from top o:: sludee to bortorn of oune: tee o• ba=;e > & OLti,T Scum thickness- 4O 1 Distance from top o; scum to top of outlet tee or ba"ie Distance from bottom of scum to bo-, o-: o;outie: tee e• ba-.e r4ky) How dimensions %ere determines Comments. trecommenda:ion icr pumping. rondition of iniet and outle! tees or baffies. depth of liquid Ieve! in rel tion to outlet invert, stru ur(a�) inte rity, evidence of Ieakat=_e. e:c.t l f i. .f L' � �. "I t GREASE TRAP:� (locate on site plan; Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffie: Date of last pumping: Comments:- - - - -- (recommendation for pumping. condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integriry, evidence of leakage, etc. (revised 04/25:97) Page 6 o: 10 SUBSURFACE SEWkE DISPOSAL SYSTEM INSPECTION FOR.A PART C ' SYSTEM INFOR.10ATION (continued) Propem Address: Ow ner: Date of Inspection: TIGHT OR HOLDING TANK: lank must be pumped prior to, or at time, of inspections (locate on site plan, _. . Depth be!ow grade. _ Material of construction. _concrete _metal _Fibergiass _Polyethylene —other(explain) Dimensions: Capactn•- gallons Design flow galions.'da. Alarm level Alarm in working order_ Yes. _ No Date of previous pu`iping Comments (condition of inlet tee. condition o a!arm and float switches. etc.t DISTRIBUTION BOX: docz:e on site p an De;:� o`Iicu!d level a00%-e ouue: in%e Comments tno:e ;f level a-d distrib.:r.or. is eaua'. evidence of solids carryov , evidence of leakage into or out of box, etc"! PUMP CHAMBER:_ (locate on site plan Pumps in working order. (Yes or No, Alarms in working order (Yes or No, Comments: (note condition of pump chamber, condition of pump and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION (continued) Propertv Add re- 7��i C�C� STA-j Owner: WLJ Date of Inspeciton: IZ*i 17 Depth to Groundwater �Z�Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation o-'Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cneck with Iota! Board o- neaa^ Chec"K Fii.titA maps Chet, pumping record-. . Check Iota' excavators. installers Use L KS Da--a r Desc%ibe in vox.e++-. v-oros r.o.+ �o:: established the :El- Croundwater Elevation. (Must be completed- go,U IS IC016-ct cc�Q ?��s C �a�tC, � sfi r� K-T76N-� b o 6� Z lrev.i.d 24.'2S•S-. Page 10 o: 10 ®wN _ c t W 'T ' 'Viol L W � w0DOW t;r 6-- ptoo-�, ui 10 VOL-) t�, d _ 0 R+• Dc c,-, ° °a te` ., �' '�'�sa� " w (� 9 I.POOU m� V at 6, �o zz" Ccl- II a�� `boo ®• 0 of y—L � .�. �P�t'f?��tJ�i N�Y✓�J ®l,Ns- N4- WkwS Atj\l,t> N o2\,.Y"A\, 0•C, 1 ' (��N1yJW` 2��\x�`� EX�Q.\O�. �J�IA-�-� - LNS(.t��'��0� �'�3 U✓ �l��G� �t14�1�W -.I. &-move -6,.Qcg,—+> u?W �� t®� ` r ; s � a8otO'�O 9 ^t f '1r q7 x - f g' _ . .� .. , .. '�i,:ems �•" ``K`,. _ _ � '�� Jx 3j — . T n _ 3 VA! z '7 — F All4 � , in ITT a _ wR Phi �y R y J Z z a ........._. -,. -- — - - --- r 9111 Sim i 'Rao 3; .�� -- .��.:...,�.:-„� --�--=_.�.0 �. ..._ ��..-::. .--.•d D�._; �;=max ._..e._ _ -�.:'�-_ :��, _. i i� k fi t �F