Loading...
HomeMy WebLinkAbout0808 OLD STAGE ROAD - Health 8)8 OLD STAGE RD., CENTERVILLE fiff UPC 12534 � No.2 153LOR lU1iTINai�YM i -' TOWN OF BARNSTABLE [L:OCAkfN L) C�.L T7f �' �P,� SEWAGE # W ^ J�- Q-- V 4Z ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO.�� 41V S- V- 77S—e?7.7 C SEPTIC TANK CAPACITY ����LZ) LEACHING FACII,TTY: (type)�� �!J L�''1� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:_ COMPLIANCE DATE: Separation Distance etween the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by D � e - 4 t3 0 ' rtv 1) TOWN OF BARNSTABLE LOCATION'��� � �� -��_ SEWAGE # VaJ AGE ASSESSOR'S Mj%P .R.r. LOT �t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) fo -L NO.OF BEDROOMS 127-0 BUILDER OR OWNER d4�� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to tti R^"^ FT --� i4P' Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fer. Edge of Wetland and Leaching Facility(If any wetlands exist ( within 300 feet of leaching facility) Furnished by �� ��° ,L � � _ e� � . l ��-1Z� ��aS t �- t$t e ��� a� /�3" �''06 � `�3�'311 TOWN OF BARNSTABLE by . OIL '8 Og CU R(9— SEWAGE # VILLAG ASSESSOR'S MAP & LOT— INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY k VCyc 906 LEACHING FACILITY: (type) TA- (size) 6 X NO. OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: r - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility C�' Feet Private Water Supply Well and Leaching Facility (If any wells exist�} on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) c� Feet Furnished by _A tta e J re9 lv� v 1 �F >o TOWN OF BARNSTABLE �� LOCP�..JN' ��^yg �,� ��S!_ �►�V` SEWAGE # VII: AGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY oo Ca LEACHING FACILITY: (type) l (size) k 000 G 0J NO. OF BEDROOMS BUILDER OR OWNER C-_U �e ` �r U sA PERMITDATE: ATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � � � . ., l :. _, 3 .. � � . �t : � �s, �; ���� . Q/ 1 40 .00 Fee No. /6� — 3a� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for &$pOga1 *p5te.m Coi%tructtun Vermtt Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 808 Old Stage Rd Steve Fahy Centerville P.O. Box 234 Installer's Name,Address,and Tel.No. DgiyrPl RYme ress and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder 0o) 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 3 high capcity inf itrators Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until.a Certifi- cate of Compliance has been issued by this Boarjof 1WIth. Signed Date `— Application Approved by Application Disapproved for e fo owing reasons Permit No. 7/ J o1 -�_ Date Issued R _ rl,�.� ...,ss r p:,"�''�`?`'"''"""s ,,.�`...�..,..r.,���;,.-x,... _ ^n.^` I y��• 7 •(.J�z, .l .`rr�� .t r.:r .. .....:_ } <' ., - r.f' r'a�._ M Y No. /�a - or11»� .,,. Fee 4 0.0 0 5 THE COMMONWEALTH OF. MASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLEs MASSACHUSETTS 01ppYicatiou for Mi!6po.5a[*p!5tcm Construction Permit Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at: R € Location Address or Lot No. x Owner's Name,Address and Tel.No. ^"r 808 Old Stage Rd ,,h .. Steve Fahy Centerville P.O. Box 23.4 Installer's Name,A dress,and Tel.No. D A(N me, ress and Tel.No. W.E Robinson Septic Sery _ P.O. Box 1089 rpnte J Type of Buildings a 1 Dwelling No.of Bedrooms 3 Garbage Grinder 40) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 4 x 1 Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date jTitle f Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 3 high capcity infibrators ' s Date last inspected: Agreement: { The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance withlthe provisions of Title 5 of the Environmental.Code and not to place the system in operation until'a Certifi- cate of Compliance has been issued by this BoarJof it`h. (� 4` Signed ,�1�� Date --/ °"7 , Application Approved by Application.Disapproved forYie fo owing reasons : J Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS F Certificate of Compliance THIS IS TO EFF�tllat the On-site Sewage Disposal System installed( )or repaired/replaced( x)on b o nson Septic ery for Steve Fahy as 808 Old age ud Centerville has been constructed in accordance rc with the provisions of Title 5 and the for Disposal System Construction Permit No. 3 a X dated' Use of this system is conditioned on compliance with the provisions set forth below: No. 6 l/ ?_ `�-�- Fee 40.00 Fahy THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Migoar 6p5, tem Construction Permit Permission is hereby granted to W.E. Robinson Septic Sery to c str ct a air( X)an On-site Sewage System located at dUd Old Stage Rd �"en e rvi� e '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. All construction must be completed within two years of the date below. i Date: Approved by AD i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, l , hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at d /'d t% l meets all of the following criteria: 1 • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED: 6 i DATE: G LICENSED SEPTIC 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]. v .�,. �- , � � � � y i i �j/�" �✓(/✓ 1 � L .--� G lit -� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner owner's Name information is Centerville MA 02632 5/2/14 required for every CitylTown State Zip Code �of Inspection page. Inspection results must be submitted on this form. Inspection may not be altered in any th way.Please see completeness.checktist at the end of the for : Important:When A. General Information filling out forms on the computer, use only the tab 1• Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. NEIGHBORHOOD WASTE WATER SERVICES Company Name 350 MAIN STREET Company Address W.YARMOUTH MA 02673 City/Town State Zip Code 508-775-2820 S13255 Telephone Number Ucense Number B. Certification 1.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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ° Needs Further Evaluation by the Local Ap roving Authority 5/2/2014 Inspector's Signature Date system inspector shall submit a copy of this inspection report to the Approving Authority(Beard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or . ` � -� has'a�design now of 10,000 gpd or greater,the inspector and the system owner shall submit the r46rt 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 scribes;conditions at the tte of kapes and trader the.condt�ons of use at thattbne.` wp .d0"n0t Wtess# 11r.the te.f erir�e under the same or different conditions of use. TdIa.5 o F s s Sy stain Pap 1 of 17 GSiru•3M3 F r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owners Name information is Centerville MA 02632 5/2/14 required for every Citylfown State Tap Code Date of Inspection page. B. Certification (cost.) 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 consists of a 1000 Gallon septic tank with concrete baffles.A concrete distribution box. and 3 high Capacity infultrators Infultrators appear to be dry and in goal working order. 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 folkA. ng 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): Tits 5 offidal kgxmbw Form:Subadew Sewage pWposal system•Page 2 of 17 t5ais•3M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments , y 808 old stage rd Property address Fred Natusch Owner Owner's Name information is Centerville MA 02632 5/2/14 required for every State Zip Code Date of Inspection page. Cityrrown 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(!XW mat the.system i not fuhc ing,ln;a.maner which will proteect 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 TNe 5 ofNdW ftpection Form:Sbefa00.Sewap Disposal System-Page 3 of 17 t5ins•3/13 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owners Name information is Centerville MA 02632 5/2/14 required for every page. Cityrrown 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 c due.to an ovedoaded.or clogged SAS or ol ❑ 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!a day flow Lr*m•3113 Tdte 5 Mgmnam Form:Subswlace Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner owner's Name information is Centerville MA 02632 5/2/14 required for every page City/Town State Zip Code Date of lnspedion 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. El ® 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 cordofm 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 daterry ine 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 16,000 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 ❑ El Area 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 0.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 Ti fnsp Title 5 offidal edt0nme Fo Soagfaoe Sewage 01sposW System•Page 5 of 17 Commonwealth of Massachusetts JERNMo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is Centerville MA 02632 5/2/14 required for every page. Cityrrown 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? ® El available 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: 1.10 gpd x#of bedrooms): 330 � t5ins•3113 TAIe 5 oFx b"pechm.Form:Subsufaoe Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner owner's Name information is required for every Centerville NIA 02632 5014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system consists of a 1000 Gallon septic tank with concrete baffles. A concrete distribution box. and 3 high Capacity infultrators. Infuitrators appear to be dry and in good working order. 2 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 Water meter readings, if available(last 2 years usage(gpd)): 2012 Detail: Sump pump? ❑ Yes ® No occupied Last date of occupancy: Da Commercialflndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CNIR 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? 0 Yes ❑ No Non-sanitary waste discharged to the Tide 5 system? ❑ Yes ❑ No Water meter readings, if available: t5irts•3M3 Title 5 offictWhsp Form:Subuface Sewage Disposal System•Page 7 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owners Name information is required for every Centerville MA 02632 5/2/14 page. cityrrown 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: none Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 of the DEP oval. ❑ Tight tank.Attach a copy appr ❑ Other(describe): 3 High cap infultrators t5ins-3113 Title 5 oridel Inspection Form:&6sulaoe Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Droner owner's Name information is Centerville MA 02632 5/2/14 required for every page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 18 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24" Depth below grade: feet Material of construction: ®cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 100+ feet Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): 18r, 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 1000 Gallon Dimensions: Sludge depth: t5ins•3113 Title 5 offidal hspscfiw Form:&baafaw Sewage Disposal System•Pape 9 of 17 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is required for every Centerville MA 02632 5/2/14 page. Cityrrown State Zip Code Dab of Inspection D. System Information (cont.) Septic Tank(cunt) Distance from top of sludge to bottom of outlet tee or baffle 36"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 32"s Distance from bottom of scum to bottom of outlet tee or baffle 28"s How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Levels are normal pumping recommended if over two years. 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 TNe 5 Offiee►9tspedionfomr Subwzfacs Sewage Disposed System-Page 10 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is Centerville MA 02632 5/2/14 required for every State Zip Code Date of Inspection Pap. CitylTown 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.): No pumping records provided by BOH Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): •Attach copy of.current pumping contract(required). is copy attached? ❑ Yes ❑ No TO 5 officjW Urepection Form:Subs Sewage asposel System Page 11 of 17 L'Sms•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is Centerville MA 02632 5/2/14 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert level and solid 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.): No signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins 3 The 5 Official Forth: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 808 old stage rd Properly Address Fred Natusch Owner Owner's Name information is Centerville AAA 02632 5/2/14 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3 ❑ 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.): 3 High cap infultrators 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 TtW 5 official br4x=fiw Form:Subudace Sewage Disposal System-Page 13 of 17. t5ins.3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owners Name information is required for every Centerville MA 02632 5/2/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): The system consists of a 1000 Gallon septic tank with concrete baffles. A concrete distribution box. and 3 high Capacity infultrators. Infultrators appear to be dry and in good working order. No signs of failure or ponding. 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•3h 3 Title 5 Officiel kspedion Form:Subsurface Sewage Dispose!System•Page 14 of 17 Commonweakh of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is Centerville MA 02632 512/14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 rdb 5 offidal!mow Form:Substdace Se wage W%wsel System•Page 15 of 17 �e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is Centerville AAA 02632 5/2/14 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 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. 10/27/82 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing.th&inspection Reports please see_Report Completeness Checklist on next page. t5ins•W3 TtW 5 offtdal h spedon Forth:SubsLOace.Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 old stage rd Property Address Fred Natusch Owner Owner's Name information is required for every Centerville MA 02632 6/2114 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked. ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5im•3113 ride 5 orficmd kgxxbm Form:Sftufaoe Sewage DlsPMW System•Page 17 of 17 • 5- bud 4 a 4. Commonwealth of Massachusetts 93 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15� 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road, Centerville MA 02632 February 7, 2012 required for every State Zip Code Date of Inspection page, Cityrrown 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 on the computer, use only the tab 1. Inspector: -4 key to move your , cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address South Dennis MA 02660 CitylTown State Zip Code (508) 385- 1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance q, n sit 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 l = `j February 7, 2012 Inspector's Signatur 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. �I Z�o .1 '� Title 5 Ofriciel Ins n Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins-11M 0 r T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is required for every 808 Old Stage Road Centerville MA 02632 February 7, 2012 page. Cityrrown 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): N/A t5ins-11/10 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 '< 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road, Centerville page. City MA 02632 February 7, 2012 required for every /Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t5ins-11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 808 Old Stage Road, Centerville M - 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road Centerville MA 02632 February 7 required for every ry 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is g08 Old Stage Road Centerville page. Ci MA 02632 February 7, 2012 required for every tylTown 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. El ® 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 ❑ El Area 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t5ins•11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road, Centerville MA 02632 February 7 2012 required for every , page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate"yes"or"no"as to h y each of the following: Yes No Pumping® Elin p g information o anon 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts SK Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road, Centerville MA 02632 February 7 2012 page. City required for every /Town State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: 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 11=57,000 gals. Water meter readings, if available(last 2 years usage(gpd)): 10=55,000 gals. Detail: Sump pump? ❑ Yes ® No occupied Last date of occupancy: Date Commercial/Industrial Flow Conditions: N/A Type of Establishment: N/A Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No N/A 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 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is 808 Old Stage Road Centerville MA 02632 February 7 2012 required for every � , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped on 12/6/99 per info from BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. ogy. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Forth: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 J�. 808 Old Stage Road, Centerville M - 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is g08 Old Stage Road, Centerville MA 02632 February 7 2012 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: Tank, d box and leach pit are original to home Infiltrators were installed on 7/19/96 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18"+ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): N/A Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 5'X9'X6' 1000 gallon Dimensions: 41' Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M y 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information equir for is every 808 Old Stage , required for eve ge Road Centerville MA 02632 February 7, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8" Scum thickness thin layer Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet baffle and outlet tee were found present and in working order. Filter present in outlet tee. No evidence of leakage or damage was found. Tank was not in need of pumping at this time Grease Trap(locate on site plan): N/A Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions : N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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 s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is required for every 808 Old Stage Road Centerville MA 02632 February 7, 2012 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A N/A Dimensions: N/A Capacity: gallons Design Flow: N/A 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.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is Stage Road, required for every 808 Old Centerville MA 02632 February 7, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order with equal distribution to outlet lines. No evidence of solid carry-over or backup in the past were found at the time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 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 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is required for every 808 Old Stage Road, Centerville MA 02632 February 7, 2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6'X6' pit with2' of stone ® leaching chambers number: 3coltec infiltrators with 2 of stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Water level in pit was approx. 18" below inlet invert. Checked stone around infiltrators and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w ,.•'y 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is required for every 808 Old Stage Road, Centerville MA 02632 February 7, 2012 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 Old Stage Road, Centerville M- 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is required for 808 Old Stage Road Centerville MA 02632 February 7, 2012 page. CityrTown 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 C. � l ZS ' O 0 3 30'3 '' 3 ` &0 t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 808 Old Stage Road, Centerville M - 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is Stage Road, required for every 808 Old Centerville MA 02632 February 7, 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: e Check Slope p ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 25.4'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 hole within 150 feet of SAS ( 9 ) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: SDW 252 Zone C 47.0' 1.6'adjustment You must describe how you established the high ground water elevation: Hand augered 3' below bottom of leaching with no water found at a depth of 12.0'. Groundwater adjustment at the time of inspection was 1.6'. Bottom of deepest part of leaching at 9.0'was found not to be located in the high groundwater elevation at the time of inspection.USGS groundwater map estimates groundwater at approx. 25.4'. Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 808 Old Stage Road, Centerville M - 192 P- 189 Property Address Sarah O'Reilly Owner Owner's Name information is d R 808 Old Stage Road,required for every Centerville MA 02632 February 7, 2012 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 i CONCV!'ONWEALTH OF MASSACHUSETTS EXECTJTrvE OFFICE CF ENVIRONMENT.AL AFF_4IR:, 4, DEPARTMENT OF E-,' NN IRONMENTAL PROTECTION; TITLE ; OFFICIAL INSPECTION FORM—NOT :FOR VOLUNTARY ASSESSMENTN SUBSURFACE SEWAGE DISPOSAL SYSTEM FORA PART A CERTIFICATION /Q Property Address. _)g oul 10 It le MA AA Owner's Name: AK. T® � 99QOr Owner's Address: a� �N�Fe C {Date of Inspection: t1 a 6�� y�`ry FjOr�e< Name of Inspectoi'l.Ro-A ate print) Company Name: �, _ rl-o.ts lhe�.� �►13�C�iTtOks Mailing Address: 'i16 _ Telephone Number: ,y�S•}f ? - bOe CERTIFIICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information :pond below is true, accurate aid complete as of the time of the inspection.The inspection was performed based or. ny ' training and experience .n :he proper function and maintenance of on site sewage disposal systems. I atr, a Ll::P approved system inspe.:tor pursuant to Section 15.340 of"title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signah:re.: u410�9 Date: 0 The system inspector shall submit a copy of this inspection,mport to the Approving Authority(Board of Hea.1 or DEP)withui 0 days of completing this inspection.If the system is a shared system or has a design floe of 1),000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o£tic.:c::'the DEP. The original shouid be sent to tte system owner and copies sent to the buyer, if applicable,and tht:aphioving alitilGritl'. Notes and Comments "*"*This report only cescribes conditions at the time of inspection and under the conditions of us° at t rat time.This inspection does not address how the system will perform in the future under the same or dil erent conditions of use. Title 5 Inspection. Form 5%15/2000 pave i y Page 2: of I 1 OFFICIAL INSPECTION FORM—NOT FOR VULIoNTARy ASSESYN E'NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO' P201 PE1,RT A CERTIFICATION (continued) Property Address: _ t7 . Owner: e' �I Date of Inspection:_ lot Inspection Summs,ry: Check AAC,D or E/ALWAYS complete an of Seetiae D A. System Passes: I have not fecund any info,:-mation which indicates that any of the failure criteria described in 310 CIvLR 15.303 or in 310 CIAR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Condi:ionally Passes: One or more:system components as described in/aappp section need to be reph.+:ed or repaired.The system, upon completion of the replacement p p , approved v d b the Board of Healt. will p,u Answer yes, no or rot determined(Y,N,ND) in the iments. if"not detenni;nc."please explain. The septic tank is metal and over 20 years old* •the septic tank(whether metal or not) is s:.Tuctiirally unsound, exhibits substantial infi:tration or exfiltrat' or tank failure is imminent System will pas;insi:etuens:if the existing tank is replaced with a complying septic as approved by the Board of Health. •A metal septic tactic will pass inspection if it is etim lly sound, not leaking and if a Certificate of Cc, rpli mce indicating that the Ltrlc is less than 20 years is available. ND explain: Observation oi•sewage bac or break out orihi�gh static water level in the distribution box due :a brakem: ar obstructed pipe(s)cr clue to a bro.` n,settled or uneven clstriibtuion box.System will pass inspection if(with approval of Board cf Health): _ broken pi*s)as zeplacad obstruction is rtmo•red distribution box is beveled or replaced ND explain: / The syste ,•ecluired pumping more tha2►.4 times a.year due to broken cr obstructed pipe(s).The :;ystem will pass inspection ' (with approval of the Board of Health): broken pipe(s)are replaced obstruction is remov,d ND explain: Page 3 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT`; SUBSUFTACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t 158 0 a c5'f" Owner: snxRl �a.5 i Date of Inspection: ) C. Further Evaluation :�s Required by the Board of Health: Conditions exist which require further evaluation by he Board of Health in order to determine if the ;ystem is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance ith 310 CMR 15.303(1)(b) j'rat rbe system is not functioning in a manner which will protect public ealth.safety and the envirorinumt: — Cesspool or privy is within 50 feet of a surface water ___- Cesspool or privy is within 50 feet of a borderin;vege ed wetland or a salt marsh 2. System will fail unless the B/Halth (a d Public Water Supplier, if any) determines that.he system is functioning .n a manneects a public health, safety and environment: The system has a septic sorption system (SAS)and the SAS is within l00 feet of 3 surface water.supply or tributace water supply. The system has a septic OS and the SAS is within a Zone I of a public water supply. — The system has a septic tiS and the SAS is within 50 feet of a private water supply we_ The_system has a septicS and the SAS is less than 100 feet but 30 feet or more from a private water supply well" Iethod used to determine distance "This system p<ss/ia well water analysis, perfo:-med at a DEP certified laboratory, for coliforri bacteria and volatilt compounds indicates tha:the well is free from pollution from that facilh- and: the presence of a:nrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria art: q A copy of the analysis mist be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT-FOR y0j•NTA�ty ASSEc;S:VI;KN'TS SUBSURFACE SEWAGE DISPOSAL SYSTEM U4SPE4L-MNFO1U4 FART A CERTIFICATION(continued) Property Address: r 0 �5 41 K � Owner: � d Date of Inspection: p/ D. System Failure Criteria applicable to all systems: You rnuWt indicate:"yes"or"no"to each of the following for ajl inspections: Yes No Backu i of sewage into facility or system component due to overloaded or clogged SAS or :esspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an o%::rloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or cloggi:d SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '.!:dray now Required pumping more than 4 times in the last year NOT due to clogged or obstructed pip;(s) Niu tbe., of times pumped__. _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any pc pion of cesspool or privy is within 100 feet of a surface water supply or tributary'to surface water::upply. 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 privai water supply well with no acceptable water quality analysis. (This system passes if the well w;at(:r anal)si:;, performed at a DEI?certified laboratory, for coliform bacteria and volatile organic Ica pound<; indicates that the well is free from pollution from that facility and the presence of atn»ionia nitrogen and nitrate nitrogen is equal to ur less than 5 ppm, provided that no other i7ailarecriteria are triggered.A copy of the analysis muse be attached to this form.] A--(Ye"o)The system fails. I have determined that one or more of the above failure criteria eat:;:as described in 310 CMR 15.303,therefore the system fails_Tlae system owner simuid cozuacj:the Etoani of Health to determine what will be necessary 1p correct the failure E. Large Systems: To be considered a large system; the system must srtv;f9elLem fa with a design flow of 10AW gpd w 15,300 gpd. You must indicate either`yes"or"no"no"to each of the foil (The following criteria apply to large systems in additio above) yes no the system is within 400 feet of a s ce drinking water supply the system is within 200 fee f a tributary to a smfacre drinking water supply _ the system is located a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA}.:r a mapped Zone !I of a public 'atet supply well If you have answered"y to any question in Section E the system is considered a significant threat, or t.:swrred "yes" in Section D al) e the large system has failed. The owner or operator of any large system c.jnsider,:d a significant threat un 'gr Section E or failed under Section D shall upgrade the system in.accordance with:'.10 cMR. 15.304. 'The syst/owaer should:ontact the appropriate regional office of the Department, Page S of 1 I O:FFICIAL ViSPECTIiON FORM—NO"f FOR VOLUNTARY ASSES SIVIEN'I'S SUBSURTACE SEWAGE DISPOSEL SYSTEM INSPECTION FOR N1 PART B ,n� CHEECKLIST Property Address: � eLQ Owner: Date'of Inspection: Check if the following hzve 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 Oe system components pumped our in the previous two weeks Y Has the sys:era received acirmal flows in the previous two week period ? _w Have large volumes of water been introduced to the system recently or as part of this inspectior _ Were as bu:It plans of the:system obtained and examined? (If they were not available note z.s N,.'L) Was the fac;Ii:y or dwelling inspected for signs of sewage back up Was the site: inspected for signs of break out'? ` Were all sv-;tem components, excluding the SAS, located on site _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the con&ticn of the haffles or tees. material of constn;ction,dimensions, depth of liquid,depth of sludge and depth of sc_ n ? _ Was the facility owner(and occupants if different from owner) provided with information cn the proper m intenance of subsurface sewage disposal systems ' The size and location of the Soil Absorption Sysiem (SAS)on the site has been determined base::.on: Yes no Existing infxtnation. For example, a plan at the Board of Health. � s{► _ Determined in the field(if any of the failure criter,'a related to Part C is at issue approximation c: distance i nacceptable) (310 C MR 1 d.302(3)(b)] Page:6 of I I OFFICIAL INSPECTION FORM— NOTFOR VOLUNTARY'ASSESSN1'.ENTS SUJISURFACE SEWAGE DISPOSAL SVS� INSPECTION FORM :PART C SYSTEM INFORMATION r Property Address: 08 (�1g 4 4 i(re� s Owner: J Date:of Inspection: e FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(acttraI): .3 DESIGN flow based on 310 CIV 15.203(for examp;e: 110 gpd x #of bedrooms): Number of current residents:_�2 _ Does residence have:a garbage grinder(yes or no): Is laundry on a separate sewage;system(yes or no):Ab (if yes separate inspection required] Laundry system i.ispected (yes or no): AX — Seasonal use: (yes or no): Water meter read.ngs, if available(last 2 vears usage(gpd)):dU 1 l Sump pump(yes or no):AP Last(late of occupancy: �, - COMMERCIAL/INDUSTRL-tL Type of establishraeat: Design flow(based on 310 C,Vf7ne d Basis of design flow(seats/pers Grease trap preser.t(yes or no): Indus::rial waste holding tank prno):` Non-sanitary wast:cischarg to the Title 5 system(y�-s or no): Water meter readuigs, if av ilable: Last date of occup.inq/ e: OTHER(describe I GENE L INFORMATION Pumping Records . Source; of information: ,C'' � Was system pumped is part of the inspection yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM j Septic tank, di!tribution box, soil absorpti(msystcrr. Single cesspoo 1 ____Overflow cesspool Privy Shared.system yes or no)(if'yes, attach previous in ___ Innovative/Aitern:tive technology, gttacha co of inspection records, if any obtained from syste n owner) py ,ntrrt:st° acd°A and rna atzenaitce cor(tract (to be Tight tank `_Attach a copy of the DEP approval _Other(describe�: Approximate age of ali components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of I l OFFICIAL I?NSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN S SUBSU]tFACE SEWAGE IDISPOSA,L SYSTEM INSPECTION FORM PART C i SYSTEM INFOR NATION(continued) Property Address: 808 Owner: _��B�!aA �-�j"� Date of Inspection:_:2 ►( BUILDING SEWER(locate on site:plan) lr � Depth below grade: C Materials of constrscti)n. cast iron A40 PVC_other(explain): Distance from private eater supply well or suction line: _ Comments (on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: Je (locate on site:plan) Depth below Prade: lb Material cf constracticn: O concrete metal____fiberglass polyethylene other(exp lain) !` If_tank is metal list age:__ Is age confirmed by a Certificate of Compliance (yes or no): , (attach a ccl y of certificate) L.� Dimensions: L Sludge depth: _ 2 r Distance from top of s udge to bottom of outlet tee or baffle: Scum thickness: ^z2 0u Distance from top of s,:u:r.to top of outlet tee or baffle: � Distance tiom bottom of scum to bottom of outlet tee or tlaf le: How were dimensions determined: .�.Syr`e� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet • /v:rt, evidence of.leakage,etc.): IL rR G 5 Oct�� p tti c�` L 1A� (_�_f�l GREASE TRAP: `_(locate on site plan) / Depth below grade:_.— Material of constructic n: _concrete metal ergl;�ss,polyethylene _other (explain): — Dimensions: Scum thickness: Distance liom top of scum to rop of/etteoeuor baffle:Distance from bottom of/dence let tee or baffle: Date of last pumping: _ Comments(on pumping dations, inlet and outlet tee or baffle condition,structurai integ�riry, liqu tevels as re!ated to outlet inv_rtof leakage, etc.): Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT VOR VOLUNTARY ASSES.!IE'INTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION )FOiEIM :PART C SYSTEM MORMATION(cotatirtued} Property Address; seg of-& &S, Q2 OA Owner: Date of Inspection: 6 6 p �I TIGHT or HOLDING TANK/:�allons/da o4at time of impectian)(locatz on site plat.) Depth below grade: Material of consruc:tion: _fiberglass`_polyethylene other(expla.; t): Dimensions: _Capacity:Design Fiow: _— Alarm present(yes /ofa"larmi _ Alarm level: n working order(yes or no): Date of last pumpin Comments(cond:� and float switches,etc.): DISTRIBUTION BOX: I(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVO4 Comments(note if cox is level and distribution to outlets egaal, any evidence of solids carryover, am- evidence�)f leakage into or out of ox,etc.): PUMP CHAMB;Z-F:: (locate on site plan) Pumps in working order(yes or no)Z-h Alarms in workin;;order(yes or ro Comments(note c or,dition of pcunps of pmmps and appurtenances,ttc): Page 9 of l 1 OFFICIAL IIN SPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR LATION (continued) Property Address: 13os Q 454v=-q e i( ��—�i_ eo A Owner: �_� d Date of Inspection: 4 SOIL ABSORPTION SYSTEM (SAS): (locate oa sit, plan,excavation not required) if SAS not located explain why: Tv e ieachirig pits,numt er: 1 _ leaching chambers, number: v leaching galleries, ;lumber: leachiia trenches,number, lengt.a: leachuLe fields, number, dimensions: overflow cesspool,nLLmber: L*tnovative alternat ve system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, .evel of ponding, damp soil. condition of vtge:taiion, etc.): — CESSPOOLS: (c,:sspooi must be pumped as part of impection)(locate on site plan) Number and configuration Depth—top of liquid to diet invert: Depth of solids layer: Depth of scum layer: —_ Dimensions of cesspool: _ Materials of consuuctioji, Ldication of groundwat-.r inflow s or no): Comments ,note condition ofs ' , signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: (locate o:;site plan) Materials of consmuction: Dimensions: _ Depth of solids: Comments (note condit:or.of tl, suns of hydraulic failure, level of ponding, condition of vegetation,etc.; Page 10 of I l OFFICLU, INSPECTION FORM —NOT FMVO'ILUNTARY ASSESRd.'::NTS SUBSURFACE: SEWAGE DISPOSAL SYSTEM INSPECTION FIDIV-1 PART-C SYSTEM INFORMATION(.00ntinued) /� 1 Property Address:_909 g(.9 i Owner: 4Q�L' eAa,C Twv-:;*- Date of Inspee r SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includiig ties to at least two permanent reference landutarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 3a 49 u� 0 i Page 11 of l l OFFICIAL NSPECTION FORM— N07C FOR VOLUNTARY ASSESSME,%1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,�os Q0 Owner: Date of Inspection:_ 16,k 19 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to grc uud water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design,plans on record-If checked, date of design plan reviewed: Observed site(a)u-ting propet2ylobservation hole within 150 feet of SAS) Checked with to:a'.Board of Health-explain: Checked with to:a..excavators, installers-(attach documentation) Accessed USGS database-explain: You must descr,be hew you established the high round water elev do