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0085 OUTPOST LANE - Health
85 Outpost Lane lip Centerville A= 1.24-014 E/ S M E A D No.2-153LOR UPC 125U smaad.com • Mado In USA 40) ia�UIiD M hi IYOOIICT lti SFI �DfSR Aim rofSOMMMan�ens CFRTiiED SOLOC�ID W*VJSFWQOGRAMjMG � 6 s 0� LOCATION SEWAGE PERMIT NO. VILLAGE 1(7 TA LlE 'S NA E i AD R�jSS OUR t�\ R U I L D E R OR OWNER alecvs 96 C DATE PERMIT ISSUED A?,hr DATE COMPLIANCE ISSUED �� i �3 p c) i LOCATION SEWAGE PERMIT NO. , ,, VILLAGE I N S T A LLER'S NAME i ADDRESS ` 0 U I L D E R OR OWNER DATE PERMIT ISSUED f37 DATE COMPLIANCE ISSUED { �A .a � Ya o s 1 BACA Board of Health 4 Q gown of Barnstable No..... P.O. Box 534 t F�$..... 1 � N%gLarc�husetts 02601 �. THE OF MASSACHUSETTS BOAR® OF HEALTH W../%)..................OF........ App iratiun for Disvus al urkg Tonstrurtiun ramit Application is hereby made for a Permit to Construct (be) or Repair ( ) an Individual Sewage Disposal System at: .19kr ........ ...........................................7" Location:Address / d?_...... ...-• ...... ....... ... �r tiro � � ... 17/ . --- -- ------ W �@� o. G�/ �y/ ddress Installer d � Address Type of Building Size Lot___-zq-_.3®V---Sq. feet'!' Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons..........__........._______ Showers ( ) — Cafeteria fixtures ...................... Design Flow................V5�....................gallons per person per day. Total daily flow------- gallons. W . •. WSeptic Tank—Liquid capacit}/.QO(2.gallons Length_____ ...... Width.....4.°..._ Diameter................ Depth.......V_._-- x Disposal Trench—No...............•..... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..... .............. Diameter...1-•OA_57_. Depth below inlet.......�0..I...... Total leaching area5 f.tq-+-C PP Z Other Distribution box ( Dosing tank14 ( ) W Percolation Test Results Performed by-_L. _._.W.6-L-A: .....f_�1 _. Date...... __._._.__-. - Test Pit No. L____.__7_ -..minutes per inch Depth of Test Pit....t4�____ Depth to ground water_N®._t_....t�._77 Ps Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate4p�A?�� -� a ' •-••-------•--------....•-•----•----•-•--••----•--•-•--•--------•••-----------------•-------•-----_........ .............----......--•--•-----..._....... 0 i Description of Soil....................... .................. W ............................. •••-••••---------------•--------•-•-•..--•••-•••.-•••••--••••-•-••-•••..--•••••-•..----•-.--......... ............................................................................... V Nature of Repairs or Alterations—Answer when applicable..............................-------------------------------------_........................... ....---•...........................•------.....-----------•-•---••---•-.........••••--._..............---••-......--••.......--•-•-•... Agreement: The undersigned agrees to install the aforedescr' ed Individual Sewage Disposal System in accordance with the provisions of iI L 11 5 of the State Sanitary Co T undersigned further agrees not to place the system in operation until a Certificate of Compliance halbe i d he board of health. Signed ��-- - •- ------•------•----------••---------------------------- Application Approved By.....:•-•----•-------••-•••----• .._•--•................... ..----•• �"/ t� J ....... Date Application Disapproved for the following reasons--------------•--•-• -•-•---•---••------•-••-•••--•-•--••--------•--•-•-•-••---••............•-•-------...---•-- -----•--•......•-••-----------------•---•....._....--••••-•--------•-------••-••--•----------....._....--•..._....--•--•-----•--•----•--•--••••-•-••-••••----•-•••---.._....-•-••---•--••--••------••... Date PermitNo...................................................--.... Issued....................................................... f Date +SO THE COMMONWEALTH OF MASSACHUSETTSs BOARD OF HEALTH Tr?ftl.!.1...................OF...... J Appliration for Diapos al Works Tonst.rurtiun Vverutit Application is hereby made for a Permit to Construct (K ) or Repair ( ) an Individual Sewage Disposal System at: :�... C�n J T C V t L I_. .... �-� 7� (o g� •� - V a n •M... Location-Address not/Lot y(0 -F------1 ----• -•- N , d d ess ... a Installer Address Type of Building Size Lot___z�__-_�_�_�'V_''Sq. feet±' 1-, Dwelling,; No of Bedrooms.......... .............................._Expansion Attic ( ) Garbage Grinder., ( ) Other e of Buildin WYP. g --•------ No of persons._ Showers ( ) Cafeteria*( '+ ) p" r Other fixtures<'' . ��' e~ r W Design Flow............... .....................gallons per person per day::.-Total daily flow............................................gallons. WSeptic Tank—Liquid capacit�__4_OQ._gallons Length._._3....... Width.'.'¢___....... Diameter________________ Depth...... x Disposal Trench—No_ ____________________ Width.................... Total Length....................Total leaching area... ft. Seepage Pit No. . ______________ Diameter__-!'� - . Depth below,inlet__.__.(r............ Total leaching area5..:f:s tG MD z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed w?...:�bY.L- L�r_ C. _.____ ... Date....�_"_5.-84 ]: i----- Test Pit No. 1_______. __._minutes per inch Depth of Test Pit___-��6_ ___.Depth to ground water °_-%.___ _ A%4 Test Pit No. 2................minutes per inch Depth of Test Pit...................:Depth to ground waten"00"}TceZQEb Description of Soil_____________________ _ F4-A................................................................................ w .................... ------•------------•-••••----•----••. •-•-•••------•••---'-•-••-----•-•----------------------------------------------------------------------------------------------•---- U i Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...-•-----'--•-•--------••-'-••.••-'----•••-•'----•••------------••'•---•-••--••----'•..........................•-•••-•-•---....-••___•---••---_....•-----•-------••-'-•--•----------'•_..._....••--••-- Agreement: The undersigned agrees to install the aforedes -bed Individual Sewage Disposal System in accordance with the provisions of iIThh 5 of the State Sanitary Coe T e undersigned further agrees not to place the system in operation untilka Certificate of Compliance has pin '.ed the board of health. Signed ..-----•-"-•••-•-'" -'•-••-----•.................... Application Approved BY---------------'••••--•-•-•-- �, �•e � 4 - Date Application Disapproved for the following reasons-----------------=�-•----- ..............••-••....------'--•-•-___•-'-•-•-...'---••'-•---"--•-------••-•---•'...--••••••---'-..-----•-'--••••---'-----•-----•-----•-•-•----••--•-----'-•--•-•----•-•-----•-•-------•--•--"------- Date Permit No..----'---••-'--------••-----•• - Issued....................: � ----------------- .................................. Date .kl THE COMMONWEALTH OF MASSACHUSETTS BOARD OR HEALTH ..........................................OF Trrtilirtttr. of Toutplitanrr THIS IS T TIF That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by •-••-•-•......-•-•_...__ t Install 'J at. L . '� ----•••-- �F Y. has been installed in accordance with the provisions of T of The State Sanitary Code as described in the application for Disposal Works Construction Permit Na___ii _ '__ ____________'__. dated___.-_____-_._._________.._.-_____._._.______.._ THE ISSU NC OF THIS CERTIFICATE SHALL NOT 7CO 'leAS A GUARANTEE THAT THE SYSTEM F ON SATISFACTORY. DATE.... Y Inspec '•'---•-•'•-••s--•----------'---------••----•••-----•------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD.:O.F'.. HEALTH yOF .....................•••-•_--_._.__......_......_........ a ....................... }dd " FEE t Q g�tt n� Permission. is hereby granted f ----- ------ to Const /of=iRepa ( an ndivi al Sewage IS osal em at No. G Street .,�~----•�'-�w'� --------------- Dated------------------•--------•-•---........ as shown on the a lication,for Disposal Works Construction Permit No.PP P ------------- - DATE.................................... Board of Health -------_._--••-----------...--------------•- � , FORM 1255 A. M. SULKIN, INC., BOSTON CATION C7 Q V NO. /J�D I LLAG E f- C E DATE PLICANT � �/-/ Cy 2P o« FEE �C �O (Non-refundable ) ` DRESS TELEPHONE NO. G WEER G Cam% GtJ EC �-L / TELEPHONE NO-06 P/ 3/ TE SCHEDULED ('Applican& s signature) • • • . • o o o o o o • o • o o o o o • • • . • . • o 0 o • o • • • . • • • • o • . • . . . . . . . . • o • s • • • • • • • . o • • • • • . • • • • • • . • . SOIL LOG -DIVISION NAME DATE 6 (34 TIME ANSION AREA: YES x NO _Gd GJ�C LEie /NC ENGINEER '. WN WATERg.._PRIVATE WELL BOARD OF HEALTH D'LayGl-�C- �,J EXCAVATOR TCH: -,(:Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes ) NOTES : �qqJ x r S° W ERCOLATIOI\7 PATE: M A l ,_j C 'EST HOLE NO. J ELEVATION: TEST VOLE NO: ELEVATION; 2 2 3 ---- 6 - 7 N �` D I g ( 8 �--- a � `} 10 12 12 13 13- 1 14 L 15 tj v Hz v 15 _.SELF. FOR SUB-SURFACE SEi'iAGE : LEACHING F+E D H ?-G PITSO'� LEACHING -- �L I TABLE FOR SUB-SURFACE SEWAGE . REASONS :- -- - -�_�EF.FING PLkNS MUST SHOW NUMBER F.SSIG?�'ED ON PERC 'TEST APPL1Gn.TIOi: -_" Lr=TED IN ENT RF,Ty ?�Y p ?''' F�=�ir I. Ei� TO BOARD OF YE'�LT" - ----- May 10 2016 12:52 Jim The Inspector Man 5085349919 page 18 „ t3a - a9� . Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Outpost Lane ,v Property Address Michael 8t Nancy Farrell t� Owner Owner's Name a information is required for every Centerville MA 02632 5-6-16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out Forms on the computer, OF use only the tab �� . ..•••• Ss,9�i�� key to move your 1. Inspector: o • o cursor-do not James D.Sears = JAM ES ip key the return Name of Inspector y. _Capewide Enterprises, LLC = ;• �,' o Company Name 153 Commercial Street '�i,;,rr�s INSPE`����.� Company Address • .mom Mashpee MA 02649 CltyfTown State Zip Code 508-477-8877 S 1623 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 erformed based on m p y training and experience in the proper function and maintenanc e ce of p on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16--000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-7-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3113 Title 5 Official Inspection Form`Subsi face Sewage Disposal System•Page 1 of 17 May 10 2016 12:52 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Outpost Lane Property Address Michael &Nancy Farrell Owner Owner's Name information isequired or every very Centerville MA 02632 5-6-16 page. Citylrown State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and pit 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): 15ins•3113 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 May 10 2016 12:53 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is required for every Centerville MA 02632 5-6-16 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observatioh 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 5Official Inspe:lion Forth:Subsurface Sewage Disposal System•Page 3 of 17 May 10 2016 12:53 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Outpost Lane Property Address ` Michael &Nancy Farrell Owner Owners Name information is Centerville MA 02632 5-6-16 required for every page. CityrFown State Zip Code Date of Inspection B. Certification (cost.) 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 his less than 6" below invert or available volume is less than 'h day flow Ri.T` l5ins•3/13 Tltle5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 May 10 2016 12:53 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetits Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Outpost Lane Property Address Michael &Nancy Farrell Owner Owner's Name information is required for every Centerville MA 02632 5-6-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system,is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, . or answered'yes" in Section 0 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. 15ins•3n 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 May 10 2016 12:53 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y' 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is Centerville required for every MA 02632 5-6-16 page. Cdy(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 NIA) ® ❑ 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15 na a 3113 Title 6 Official Inspection Form:Subsurface SewageDisposel Syslem•Page 6 of 17 May 10 2016 12:53 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is Centerville MA 02632 5-6-16 required for every 4 page. City/rown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 2 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 d 2014-63,o0oGals g ( Y g (gP ))' 2015-62,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(9Pd) 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: t5in5•M3 - Title 5 Official Irspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 May 10 2016 12:54 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments UV 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is Centerville MA 02632 5-6-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? "❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): 15ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 May 1.0 2016 12:54 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V 85 Outpost Lane P rope qy Address Michael & Nancy Farrell Owner Owner's Name requir required is Centerville MA 02632 5-6-16 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: 1984 Permit#84-507/2016 New D Box. Were sewage odors detected when arriving at the site? . ❑ Yes M No Building Sewer(locate on site plan): Depth below grade: 20" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank (locate on site plan): Depth below grade: 10"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene. ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 1„ Sludge depth: 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 17 May 1D 2016 12:54 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments i 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is required for every Centerville MA 02632 5-6-16 . page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1 Distance from top of scum to.top of outlet tee or baffle 12' , Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asb Slud ui g —Tape ge 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 at working level. Tank and covers at 10 below grade. Inlet tee, outlet bafflle. No sign of leakage or over loading. Grease Trap (locate plan): locate on site : 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 i Date of last pumping: Date 15ins•3/13 - Title 6 Official Inspection Form:Subsurface Sewage Dlsposal System•Page 10 of 17 May 10 2016 12:54 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Outpost Lane Properly Address Michael& Nancy Farrell Owner Owner's Name information is Centerville MA 02632 5-6-16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below 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 t5in3•3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 May 10 2016 12:54 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts . Title 5 official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Co 85 Outpost Lane Property Address Michael &Nancy Farrell Owner Owner's Name rFormation is Centerville squired for every MA 02632 5-6-16 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20" below grade w/one line out. Box is new 2016 w/cover at 8" Pump Chamber(locate an 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 May 1.0 2016 12:54 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is Centerville MA 02632 5$-16 required for every page. Cityrrown State. Zip Code Date of Inspection D. System Informatibn (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: .. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a H 20 1000 Gal precast pit. Pit at 92" below grade w/cover at 27". 2' water in pit. No sign of over loading or-solid carry over, No high stain line 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 f5ine•3113 - Title 5 Official Ins"otion Form:Subsurface Sewage Disposal System•Page 13 of 17 May 1.0 2016 12:54 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owner's Name information is required for every Centerville MA 02632 5-6-16 page. Citylrown 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.): i 5i + t ns 3113 Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Pape 14 of 1T May 10 2016 12:55 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Outpost Lane lug- - Property Address Michael &Nancy Farrell Owner Owner's Name information is required for every Centerville MA 02632 5-6-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 15ins-3113 Title 5 Official Insoect,on Form:Subsurface Sewage Disposal System•Page 15 of 17 May 10 2016 12:55 Jim The Inspector Man 5085349919 page 33 O .S' ov7Wos T 1/N £NT BACK a A q d MG 4 t .. R-3 - aS r May 10 2016 12:55 Jim The Inspector Man 5085349919 page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Outpost Lane Property Address Michael & Nancy Farrell Owner Owners Name information is required for every Centerville MA 02632 5-6-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to6igh ground water. 43' feet Please indicate all methods used to determine the high ground water elevation: ❑ obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: SDW 252 ADJ3. You must describe how you established the high ground water elevation: U.S.G.S. Well-SDW 252 at 46'w/4'ADJ. Bottom of pit at 12' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. ISins•3113 Tide 50rficial Inspection Form;Subsurface Sewage Disposal Systerr.Page 16 of 17 May 10 2016 12:55 Jim The Inspector Man 5085349919 page 35 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Outpost Lane Property Address Michael& Nancy.Farrell Owner Owner's Name inform equine for is Centerville MA 02632 5-6-16. required for every page. City/Town State Zip Code Date of Inspedion 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 t5iris-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 or 17 2 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for Disposal 6pstem ConstrUttion permit Application for a Permit to Construct( ) Repair Oj Upgrade( ) Abandon( ) ❑Complete System EXIndividual Components Location Address or Lot No. $5 o L.)"TPoS`t'L,NC-- Owner's Name,Address,and Tel.No. Z.`✓tLc Mtd'WAEL + iv64Nd.Y 9=r4R1;GLL, Assessor's Map/Parcel 99,Joq 5 S,5 ©cJ7-POS e—Af-1 u Installer's Name,Address,and Tel.No. 5D2-q*1 7'927 7 Designer's Name,Address,and Tel.No. CAP6w10E 6iVT&JZ P0t5 G'S c. C_ NIA Co wt c--d_V 5T- mAS_qp6g Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed Date 3-,)-4—DL0tC, Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued e 1 6� 5 No. '" Fee 7:5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliCatlon for Vsposal 6pstem Construction j3Prmite Application fora Permit to Construct( ) Repair(Q Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. gs a 0TPOST L.4NG Owner's Name,Address,and Tel.No. Map/Parcel e-'✓t LOE M idOAEL + uA"c'-Y � . APP_SG( Assessor's Ma p I `�2` D t>5 LA,J6 G.EArr61Z.v((.c.E Installer's Name,Address,and Tel.No. 5p$-1417 88 7 7 Designer's Name,Address,and Tel.No. CAP&WfOE 6&-7EkPOUScS "C_ I N/A Coxtof ErZOJ Sr M A S 6-6 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ! Nature of Repairs or Alterations(Answer when applicable) I _ iUE= 'FLU 1)-1')oX -M P T Date last inspected: k Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed C Date 4`01 O(f o Application Approved by Date Application Disapproved by Date for the following reasons PermitNo. �Iu .� d Date Issued--------------------------------------------------------------------------------------------------------------------------------------- r THE COMMONWEALTH OF MASSACHUSETTS �j Q w U bx BARNSTABLE,MASSACHUSETTS CertifiratP of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(% Upgraded( ) Abandoned( )by �,'rtPcwrr�� �1�7fl2�2t SLR LL.C� at ES V?AdS'T LAAJi!;- eVTc (LLC has been constructed in accordance 2 / with the provisions of Title 5 and the for Disposal System Construction Permit No. 7616-6Y 7 dated ) - Installer PG� X 1215 � Designer N1A #bedrooms A= e Approved design flow, (� � � [� } gpd I The issuance of this permit shall not be construed as a guarantee that the system wilt-fu•ction as designed. Date S I. Inspector �A,- --------------------------- -- --------------------------------------------------------------------------------------------------------- No. ozf rO '_ 6 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS MispoSal 6pstem Construction 3prrmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at %,5 Ouyo-sT LAtJE CFuU t7 aw cl r' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permite-1 Date. �j r �{— Approved by AsBuilt r Page 1 of 1 LdCATION _ �S SEWAGE PERMIT NO. 435 pu VILLAGE Q21L i 1 TALLE 'S NA E i AMR SS b° IUILDER OR OWNER � �eCw J �a�Do•� � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Ho,,L . i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 72095&seq=l 5/5/2016 I w ` f(w3' 41 t , 0 'G a -4 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information I j �f forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name r� 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 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 U4 tu Ics July 17, 2010 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17 2010 every 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is recommended. 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-09/08 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 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17, 2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to.a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 n v❑ ® q to a overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17 2010 required for y , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 La rge 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•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17, 2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17 2010 required for Y every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 78 gpd 9 ( Y 9 (gpd)): Detail: 2008-2009 Sump pump? ❑ Yes ® No Last date of occupancy: current 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•09/08 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 85 Outpost Lane �M Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 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 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is y Centerville MA 02632 Jul 17 2010 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: Age: 25+ years. Certificate of compliance issued 8/2/84 (As built card) 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 6 ft x 5 ft(1000 gallon) Sludge depth: 4 in t5ins-09/08 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 p °M 85 Outpost Lane Property Address P Y Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) cont.Tank Septic p (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Probe to top of tank Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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-09/08 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 85 Outpost Lane 'M Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for y every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I_ f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Q° 85 Outpost Lane 4M Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17 2010 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears level with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 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 M 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to contain 18 inches of effluent with no staining into riser observed. 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•09/08 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 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul required for Y 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-09/08 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 °M0 85 Outpost Lane Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Cl 3 Q�T 2- p TANK t rA A B I ��' (7`/a Z 3 2;(Z 22,' 3 ��y2 2s 32 2 `-3 w Our�057' L WE t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ' J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is required for Centerville MA 02632 July 17 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ 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: 6/13/84 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: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 4.1 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Outpost Lane M Property Address Edward and Helen Perron Owner Owner's Name information is Centerville MA 02632 Jul 17, 2010 required for Y every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 43 OK 4.7� _ _ __47 2 _-'' _._ _ _ - - _ --- _- ro _ /"IAl+1H04 CC7V ,Q 7�0 t�f`T'f�`f/l�l ' Hol2�z. S�'/9LE� �a — o— Q---•p -- �.-r��voscd c�rovnd Pr-of� Je - � 5 C HE a 40 PVC, 0,E3 EQU19L 7-0 S&P-r1c �rr��nrrnurrt 14" per of �iB - �2� �Ge s�-►�Rc� t�e�E' VL- --3 TANK ___ _ /'U-'i. —//V-s- • D/577 SOX � " — + � , a 000 Gr94-, 5E nT"/C 7-f9AJk_ i a t f LOG C 7-le9/v A s GAL. TA?AJA-� r t d Q w .r r i � - G E/9 C f°•�1 PIT S/DEw,--4LL -1.,1. ..�Z3 F. � �� -�= ,� i� �( ti 50 V � 7 � E/1:4 C/-/ 4,62 / ,�-�7 � J ..,w. 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