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0090 PADLOCK LANE - Health
90 Padlock Lane A= 193- 191 Centerville ///T M A D No.2-153LOR UPC 12LU • Ye&Iw Uv SFI No. I� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address o of No.R b e l oc <— �p.✓�� Owper' Name ,address,and Tel.No. Assessor's Map/Parcel Installer's Name,Addye ,and Tel.No. 50F q7'7_V 7 Designer's Name,Address,and Tel.No. 0.s Type of Building: Dwelling No.of Bedrooms ®�—}-, Lot Size m-30—"A .� ft-- . Garbage Grinder( ) Other Type of Building �S I d�%v^It a, 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) wb"tQx V06 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 Healt Signed Date 5 -30 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. e2O Date Issued .5 U f�� �. No. CIP Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppIication for Disposal .6p'stem Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade.;,(--)s Abandon( ) ❑Complete System Vndividual Components Location Address o .Lot No. PC's I oc`L ,A"L-k , Owner's Name,Address,and Tel.No. 173 .!;'l 2. a 7 Assessor's Map/Parcel 9 3//1/ Installer's Name,Add s,and Tel.No,r 5J F—q 7'7_U 7 7 Designer's Name,Address,and Tel.No.rfe �+�- �v�'t�� i Type of Building:Dwelling No.of Bedrooms Lot Size a 6--A fit. Garbage Grinder( ) Other Type of Building re—S i d`N,vx l a�1 No of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) c Al; gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title i .. Size of Septic Tank Type of S.A.S. i Description of Soil i n 11 'i Nature of Repairs or Alterations(Answer when applicable) (� �?h— Date last inspected: Agreement: j 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 Date - p -da 13, Application Approved by Date 30 — 12 'Application-Disapproved by Date F for the following reasons ' <.Permit No. a O �'"' Date Issued 4----------------------- , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance a THIS IS TO CERTIFY,that the On'-sites Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by CC�J�w%Ag- CYO t L�er•,5"Q-5 ,Lk,C at /6 (�i4��1� L�.nQ has been constructed in accordance 2 with the provisions of Title 5 and the for Disposal System Construction Permit No. p 1 )-dated 5 — J 6 -Installer Cow J.�4., �v�Q� O`� � � Designer #bedrooms Z •j`''' Approved design flow gpd . The'issuance of this permit shall not be construed as a guarantee that the system willefunct on as designed., Date ? ! A Inspector . i --------------------------------------------------------------------------------------------------------------------------------------- No. 4,-VU _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair V� Upgrade`( ) Abandon( ) System located at 90 oo,-J br—k Lam„ and as described in the above Application for Disposal System Construction Permit'"The applicant recognized his/her duty to comply with t Title 5 and the following local provisions or special conditions. Provided:Construction.inust be completed within three years of the date of this permit.�"� Date ! (� Approved b PP Y Yk' .. t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When ng out forms A. General Information oln'the computer, ``��` �H OF�IyySS i,�ii i� use only the tab 1. Inspector: z��• •`qcy key to move your =��:' DAMES ��'' cursor-do not .lames D. Sears =�: i rn key. Cz use the return Name of Inspector >wr•.• Capewide enterprises, LLC ��;.cFo ��a:•o� "ITV Company Name �VIA i���F IN tC 153 Commercial Street ''��nn,,,,,,,,,ut���``� Company Address Mashpee Ma 02649 Citylrown State Zip Code 508-477-8877 S1623 Telephone Number License Number 0 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 ❑ ls ❑ Needs Further Evaluation by the Local Approving Authority = _ CD f 6-1-12 spectoes Signature Date The system inspector shall submit a copy of this inspection report to the Appr ving Autl ority(66ard of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 nspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 ' Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 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: ® 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '~ 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. Cityfrown 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO(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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has'a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑- ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 90 Padlock Ln Property Address Linda Friel Owner Owners Name information is required for every Centerville MA 02632 6-1-12 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large a 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 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? ® ❑ 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): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 y t5ins 11110 rue 5 Official Uupecuon Form:Subsurface sewage Disposal system•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal precast tank D Box and pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Forth: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 '< 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 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: 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 I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 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: 1978 Permit#78-248 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.): pipeing is 4"sch 40 Septic Tank(locate on site plan): Depth below grade: 16"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: 1000GaI Precast Sludge depth: 3° t5ins•11110 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 y 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information Is required for every Centerville MA 02632 6-1-12 page. City(rown 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 27" Scum thickness Distance from top of scum to top of outlet tee or baffle 30" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? Tape Asbuilt 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 16" below grade covers 2", inlet tee, outlet tee 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•11l10 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 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-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 '< 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16" 30" Below grade wlcover at 4" one line out Box is clean and solid Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. City(rown 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.): Leaching is one 1000 gal precast pit, pit at 30 below grade w/cover at 4",Pit is dry w/stain line at 30" Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s .y 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 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 AR 3� ° 43` 0 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 14'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger 14' no g.w. Auger hole 5' below bottom of pit Before filing 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 90 Padlock Ln Property Address Linda Friel Owner Owner's Name information is required for every Centerville MA 02632 6-1-12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmwts 90 Padlock Lane_ Property Address Linda Friel omw Owneris Name 1n16nna' eaely Centerville MA 02642 4-1342 required page. Cityrrmm state Tip Code Data 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. tm g,out fr When A. Genera! Information ft'ICurg out form \�►a►►umuunrii computer, .OF.. S4i�i on the \\�� "I" A (n key use��yew 1. tnspector. �(/�" o� q�yG cursor-do not James[}..Seam =�: JAMES .m use the return Name of ir►spedor Bey. Capewide Enterprises, LLC • o o ' Company Name :,, � FRt4 °4ej`a 153 Commercial St ���F1Sii NiSP►�G��````` Company Address Mashpee MA 02649 CitytT"n state Zip Code 508-477-8877 51623 Telephone Number License Number S. 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 0 Needs Further Evaluation by the Local Approving Authority " Jn---"�' 4-17-12 s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DER)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 DER The° m should be sent to the system owner and copies sent to the buyer,if applicatW,a the:approving auffumity. ---This report only descnbm conditions at the time of insertion and under the conditions of use at that time.This inspection does notaddrjss icw the system will perform in the future under the same or different conditions ofe "` c` a !Sins•11/10 rWe 5 Official brspeetion Farm:S1ib Sewage Disposal System•Page r or 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for voluntary Assessments 90 Padlock Lane. Property Address Linda Friel Owner owner's Mama information isrequired for Centerville MA 02842 4-13-12 iae, cityrrown state zip Code Date of inspection B. Certification (cons.) Inspection summary:Check A,B,C,D or E!always complete all of Section D A) System Passes: ❑ l have not found any information whit 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: B) System conditionally Pass": One or more system components as described in the"Conditional Pass"section new 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 tnll mWQ 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 eAlt ation 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): tarns•1 tno Tft 5 Offbef MsPeaton Fam:s„aewtace Swap Dtspow system'Page 2 to 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurfae Sewage Disposal System Fonn-Not for Voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owner Ow tei'S Name r ��ery Centerville MA 02642 4-13-12 Pap, Myrrown Stale Tip code Date of Itispec lion B. Certification (cunt.) 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): Tank Leaking at Seam ❑ 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 Evaluate is Required by the Board of Heath. ❑ 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 t5ft•11110 Ta s DNSbspeeft Fatrc She Swap Disposal System+Poe 3 C1 17 i s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owaer owmes Name tnkrmation is mquimdforevery Centerville MA 02642 4-13-12 pap, Cdyrrown state Zip Cade Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Hear(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 ropy 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of eflftmd 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 18hts•11110 TO 5 O(Idd Mspecftn Few.Subsufaoe Sewage Disposal System'Fags 4 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal system Fonn-Not for Voluntary Assessments 90 Padlock Lane! Property Address Linda Friel Owner Owner's Fume iftrmation is fo required for every Centerville MA 02642 4-13-12 pW, Citylrown State Tip Code Date of hnsjxx%on B. Cerfification (cont.) Yes No ❑ 0 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 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 N the well water analysis,performed at a DEP certilled 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 hft.I have determined that one or more of the above failure criteria exist as described in 310 CHAR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to corm the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question In Section E the system Is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5itss=iS/7d rb 5 t3ftW MVedw Form:&ZU019ce Seine MspoW System•PW 5 or 17 Commonwealth of Massachusetts Twar Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock lane! Property Address Linda Friel Owner Owner's Name ink��every Centerville MA 02642 4-13-12 PW- Cityrrown state Zrp Code Date of Inspec ion C. Checklist Check if the following have been done.You trust indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occi pant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? C7 ® 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?Of 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 interims of the tank inspected for the condition of the baffles or tees,material of cunsttuction, 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 ration 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) CMR 15.302(5)J D. System Information §Uskkw t l Flow Condltlons: 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 t5ins•11l10 Title 5 Of W hq=ft Fmm:SWMK=Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Submiface Sftuge Dismal System Fotm-Not for Voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owner Ownees Name information is requited for every Centerville MA 02642 4-13-12 pap, CityrTown State 4 Code Date of inspection D. System Information Description: The system is a 1000 Gal Precast Tank D Box and Pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes Z No Laundry system inspected? © Yes 1@ No Seasonal use? 0 Yes ❑ No Water meter readings, if available last 2 5000-2010 g ( Yam (9 }= 6000-2011 Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: NA Commerciallindustrial Flow Condkimm. Type of Establishment Design flow(based on 310 GMR 15.203): Gallons per day(Vd) Basis of design flow(seatslpetsonslsq-fL,etc-): Grease trap present? Q Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Tits 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 TWe 5 Off &upecdon Form:Stbsurfaw Sewage Mposa!System>Page 7 of 17 Commonwealth of Massachusetts Title v Official Inspection Form Subsurface Sewage Disposal system Foam-Not fear Voluntary moments 90 Padlock Lanel Property Address Linda Friel Owner owrrtees Name information is nquired for every Centerville MA 02642 4-13-12 pne, Cdyfrown State Zip code Date of talon D. System Information (coat) Last date of occupancy/use: Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes 21000No If yes,volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 0 Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow spool ❑ Privy ❑ Shared system(yes or no)(if yes,mach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance corrtrad(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): Ons+11M0 7Ne 5 OfidW tnspedon Fomf:SuDstmiew SmW Disposal System'Pam 8 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 19 Subsurface Sewage Disposal system Form-Not for voluntary Assessments 7. UF 90 Padlock Lanel Property Address Linda Friel Owner owner's Name information is required for every Centerville MA 02642 4-18-12 pap, Cityrrown State Zip Code Date of Inspection D. System Information (cunt) Approximate age of all components,date installed(i€known)and source of inforawtion: 1978 Permit #78-248 Were sewage odors detected when arriving at the site? ❑ yes ® No Building sewer(locate on site plan): Depth below grade: 2'met Material of construction: ❑cast iron 0 40 PVC ®other(explain): Distance from private water supply well or suit fine: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Piping is 4"sch 40 into Tank Piping from tank to D Box and D Box to Pit sch 20 Septic Tank(locate on site plan). Depth below grade: 16, Material of construction: 0 concrete ❑metal Q fiberglass Q polyethylene p outer(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ate) 0 yes ❑ No Dimensions: 1000 Gal Precast qn Sludge depth: tl t5irm+11110 Tifie 5 OftW hvec6Cn Fow.Sutauiface Sftvp Dispose!Symm+Page 9 of 17 Commonwealth of Massachusetts mum Title 5 Official inspection Form Subsurface a Sewage Disposal System Fin-Not for Voluntary Assessments 90 padlock Lanel Properly Address Linda Friel Owner Owner's Nance ftftffnatt° is n required for every Centerville MA 02642 4-13-12 per, Cityrrown State Zip Code Hate of 1wgwcfion D. System information (cont) Septic Tank(cont) Distance from top of sludge slu 27" to bottom of outlet tee or baffle Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 30* Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? Tape Asbuilt 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 and outlet ever at 16"Below Grade inlet cover at 2", Inlet Tee, outlet Baffle Tank is Leaking at seam Grease Trap(bate on site plan): Dept below grade: feet Material of construction: concrete 0 metal 0 fiberglass 0 polyethylene 0 other(e)plain): 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•11110 We 5 MW tspecdon Form:Subsurfew Sewep Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Doposal System IFwm-Not for voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owner owner's Name is �,��every Centerville MA 02642 4-13-12 pap, Cityrrown State zip Code Date of Irion D. system Information (cont) Comments(on pumping recommendations,inlet and outlet tee or baffle condign,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tanis(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑Polyethy ❑other'(min)= Dimensions: capes' ga�orts Design Flow: geRons per day Alarm present 0 Yes 0 No Alarm level: Alarm in wrong r ❑ Yes ❑ No Gate of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? [{ Yes 0 No On•ttitb Tift 5 MW kispedion Form:Substuface Sewage t*rod System•r'fte It of 17 Commonweaft1 of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Lanel Property Address Linda Friel owner owner's time Worm fo 7 r e required for every Centerville MA 02642 4-13-12 Pap. e4ffown State Zrp Cade Date of hupedion D. System Information (coa) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 011 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" 3Ci" Below Grade One line out, Walls are gone on Box Needs to Replace D Box Pump Chamber(locate on site plan): Pumps in working order. Q Yes Q No Alarms in working order. Q Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenance,etc.)-. Soil Absorption system(SAS)Gate on site plan,excavation not required): If SAS not located,explain why: t6tns•ttrto Tift 5 ogfft kepeefim Form:Subswf w Sewage Symm+Pop 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Ubsurfacm Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owner Owner's Name information isrequiredforemy Centerville MA 02642 4-13-12 pap, Cityfrown state 25p Code Date of Insperfion D. System Information (cont.) Type: leaching pits number. 1 ❑ teaching chambers number_ Q teaching galleries number:. ❑ teaching trenches numb,length: ❑ teaching fields number,dimensions: ❑ overflow cesspool numb: Q innovativelatternative system 7ypelnarne of technology_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Leaching is one 1000 Gal Precast Pit, Pit at 3(r Below Grade w/cover at 4" Pit is dry,w/stain fine at 30" 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 Q Yes Q No •TrrtaTWO 6 moo„Form suasuftm Sewep DWpmd symn•Page 13 or17 Commonwealth of Massachusetts am Title 5 Official Inspection Form subsurface Swwi qe Disposal System Fmm-Plot for voluntary dents 90 Padlock Lanel Property Address Linda Friel oar owners wanve information is required for every Centerville MA 02642 4-13-12 Pap. City/Town State zip Cade Date of trispection D. System Information (cont) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins•i t/10 TWO 6 O fspection FOM'&ftWf9C0 Sewage Disposal System+Page 14 of 17 Comnommmith of Massachuseft Tie 5 Official Inspection Form Submftce SwjaW Mapmal Sysftm FOM W Padkck Umml UuWa Aftfms OWWs14&-m MA =42 4.1.1-12 ftta D. Sim Inf6mat n (cont) Sketch Of Sege DmpesmSvstem P tkhe a view of the to at kuW'fart,pemment re€erence marks or bend Locate af#web wftn 1W feet Locate wtwe ng..CJvxk om of ft 0 drag f� . ..:.. We------------ r _ ,..... Ls f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 90 Padlock Lanel Property Address Linda Friel Owner Owners Name information is required for every Centerville MA 02642 4-13-12 Pap. Cityrrown State Zip Code Date of ke ion D. System Information (corn,) Site Exam: ❑ check.Slope ❑ Surface water Q Check cellar ❑ Shallow wells Estimated depth to high ground water: 14'# tees Please indicate all methods used to determine the high ground water elevation: Q Obtained from system design plans on reoDrd If checked,date of design plan reviewed: gate Observed site(abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) Q Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand Auger 14'no G.W. Auger Hole 5'Below butiorn of Pit Before filing this Inspection Report,please see Report Completeness Checklist on next page. M-4.1 ttto IVO 6 Oft Fom-.stbswlew S&WW Disposal SYSWn-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface""go Disposal system Form-Not for Voluntary anent N Padlock Lanel Property Address Linda Friel Owner chwMes Name information is Centerville MA 02642 4-13-12 Pap. citylrown stag zip node Oft of Irispedion E. Report Completeness Checklist ❑ Inspection Summary:A, B,C,D,or E coed ❑ 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 11no Tfft 5 MW kapecom Form:Shrew SOWW Di POW SydUn°Pap 1T of 17 LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISS-UED -7-J*- 7 r �� 3 y� � 9 s '\`z n VP) No.............. q I THE COMMONWEALTH '�H OF MASSACHUSETTS BOARD ,91f HEALTH DW13 . V-5$ k ...........I ...............OF...........:7........4. Appliration for Uhipaoat Works Tilustrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal ...ystem at: 02 . .......... ...... ........................... .....................................L.10 -) i r................................................. Local�,n-Address ,e NLo- Ur 5'7/40 L6 0"6r W,34P �r Lot .................................. E40........-I........----........................ owner �4 Address 6�c.............g ....................... ............... .......... . Installer Address Pq Type of Building Size Lot ......Sq. feet U Dwelling—No. of Bedrooms...............5......... Garbage Grinder ................Expansion Attic aOther—Type of Building ............................ No. of persons........_.__._.............. Showers Cafeteria es . .< �Other fixtu .................................................................................................................................................... . W Design Flow.............5.t:�......................gallons per personArr day. Total daily flow___.........-45-n.................gallons. W4 Septic Tank—Liquid capacity-tCM.gallons Length_' Width..4j—!O. Diameter................ Depth..._........._. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.... ...sq. f t. Seepage Pit No----------I......... Diameter----- &...... Depth below inlet.......CP Total leaching area....0.0 ..sq. ft. Z Other Distribution box ( ) Dosin4 tank ( ) Percolation Test Results Performed byA5A;CT.b.qL.!:A4A.... A.!L-.4.t 6.4......L ...Re Date..A.-?-'l Test Pit No. I..... ---minutes per inch Depth of Test Pit------M...... Depth to ground water........................ fTq Test Pit No. 2 .........minutes per inch Depth of Test Pit..._-.._........_... Depth to ground water.._.....___..._....._._. 1:4 t)-2, rwl-..-_.,_-1,,............7,=...1A,.,-A.................................................................................................. 0 Description of Soil........C�0&ka$- M....... ......FV!M........e2j4:��........................................................................................ W .... L) .........7.............................................................................................................................................................................................. ---------- ............................................................................................................................................................................ UNature of Repairs or Alterations—Answer when applicable:_......................................................... .................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I'i U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h Ith Signed ... ..... .............Z/ .. ............................ ----- .......... Application Approved By...... . ..... ..... . Date .. ...... . .... ................... ... Date _ Application Disapproved for the following reasons:................................................................................................................. .......................................................................:.........................................................................................I....................................... Date Permit No......................................................... IssuedL..7-3-7 f— .................................................... Date T-#&i L-;,f >~t.nu✓ a 11C> x 3 330 4.Pt7. d uaF--t c Y k = 3So., 150 % - 4-95 6.P .D. Jl U sue- t o oca 6..a.L-. F'oSAs. PiT - t-)SE. lacx=, 46&L-. �twEi S1IwIwYIf�.�w1+ I rwl 1 rww�'\rr I w Ir I��II�I\I\rllwi�l � -,` \ ♦`, �� P�jP 'Sir 9 2.'S s .P.V. '$ICST-Y'OAA AZSA, bT". n f// f►j=. A TcdrA L -p e6tQlj : d25 6•.p r=>- ToT&L. "C)A-t t>f 1=t..a VV r 33D 6PV- G�GDLATIOt.,I RATr~ ��I�U �1..1'vtr►J�OQ �,5, 'e. � 15,�� o ,NsOF E n. A IrelsT tuv. L.aAA O d I voca µN GAL 5d} 4'�0� t iw• GI. Ir 2 'Box Sepric INV. I Co loc>O _tIwv wv. i, / GAL. -. L%AcN 'A \,v t ru j Av t"(u E wASi16tS � r SprJ*7 3tra.r6. CS ZTIFtr--C? PPzn�-t L� - L dC.A►TI O" e1E.MLVIL T M GCtz*rl---,{ T14Ar TNP.r "tvj3l.tAQt, 5"0%k/ ► Pt-A1.J RT=- E—McZE W 1 TA TN;.: 51 D G� U► E-- AWM, SC-Tt---ACV- j7C-QUtCEM&-WTS OP TNf~. ? J� 3 Ta w LJ /OP 'BA Q L , G 4PL.A 0 GATE (�� ` U 13/��CTC�2. , tZEGIS(C.iZitiD LAIWG Z-t-�1 a C7C_A!J !S 1JOT P3A�,P�.'C? p�..� A,�J 05TEG'.�/1l»LG v 1�tCASrs1 ltJst`�J.tnt��J i �ivc.v► �{ T�tt:: L�F4:'S T4 SNarr,Yt-b ,I7L t,k:f Cc. U"BUD ro »c-.T-cV-Mik.tt- LC)-V QoseZT V1, cam. LYDW No......................... l Fmc 2...F...!4.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TO U)-#_�................OF......... •b2 ' - Appliration for Elispnan1 Works Tnnstrnr#iun Prr, tit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: q ...�...�...�...e...,.-..�...'.._._..�.....:..�....G.p.... ........................... ..U...•.N.=.-.}.................................... .....................d.....................r...L..o.t..i.N..o.....:...�.........A....�...�.U..S....t..�..........�. Addre ----•-•--•...... . ...j . ................ --- ............................................... "aaG I / Owner Address fi ill 7 Q It C T{�Altry.t14?,€?/�{��...�A 1Fr�'----........ �!l l�!tJ 5 r1tS��t�. • a -••------•----•---••--- ............... � Installer Address , d Type of Building Size Lot_____�_` �..'��._ _' .....Sq. feet U Dwelling—No. of Bedrooms______________ _________________________Expansion Attic Garbage Grinder ( ) pa-, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fires W Design Flow............. `"?_________.____._____._gallons per person per day. Total doily flow................ ____.___.______._gallons. 9 Septic Tank—Liquid capacity�9 ?_gallons Length__ _' ___ Width:: .'19�__ Diameter________________ Depth................ x Disposal Trench—No_____________________ Width............ Total Length.................... Total leaching area.... .._ ._.---sq. ft. Seepage Pit No_________ __________ Diameter.........irp _..__ Depth below inlet......�a•........ Total leaching area.... _Q ..sq. ft. Z Other Distribution box ( ) Dosin tank ( ) W Percolation Test Results Performed by 'e _ __'�:�°�ll ...._"__ i�'.��__._0fJO ►: Date._ _............................... _1":_1-7 ------------------------ ,4 Test Pit No. I.._._ .-___minutes per inch Depth of Test Pit_____.J_' ....... Depth to ground water________________________ Grq Test Pit NQP 2�._,........minutes per inch Depth of Test Pit____________________ Depth to ground water........................ O w - ^ i�l aJ �:a R.1r.. x i .._.__... ..........--- -- --- ------------------------------•--------•-------------•---•----------------•••-------•-••- Description of Soil____.___ U ------•------------------------- ------- ___-_----------- •---------------------------------------------------------------------------------------------- ------------------------ -----------------------------------------W U Nature of Repairs or Alterations—Answer-when applicable_______________________________________________________________________________________________ -------------------•----•---•------------------------•-•----------•-----------------........-----------------------------------•---------•-------------------------------------------._..........___.__- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the'State Sanitary CodeT4 The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuQ by the board of health. Sid ! -----------------•- _._ _!zi..._--- Date Application Approved By. :__ ' Application Disapproved for the following reasons: ----•---- .......................................-•---------•--•--•-------•--•-....--•-•------•......-•-------•----•-•--••-•-•---•---•-•--------------•------------••-•--•----•---------••••••--------•------•--- t Date PermitNo................................................... . Issued......................... ----•---•---•---•--•-------• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH ... oF...-..... w ....................... .................... (�rr�#ifirtt�le of 'f�nrnt��i�anr� ; Isis � IFY That the Individual Sewage Disposal System constructed or Re aired g P �' ( ) P ( ) by dL ..._ : ...... ........ . .: + ` ------ \.D F ' Y taller 1 r has been installed in accordance with the provisions of r 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit �� ._'�"_jr',__................ dated,J#1 _*._-_7- ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ - a :...:.. Inspector ""'"' THE COMMONWEALTH OF MASSACHUSETTS +� BOARD OF HEALTH No.................'....... FEIQ- ................. �i��,a tt1 nrk � n� �r#ilan lera�ti� Permiss s hereby granted #� *- to Crtr ( )f or Repair ( I> iiv u 1 rag�re, osR4 System at N�C d �l .ems f v p_�j ♦4 'r •ter '^ Street as shown on the application for"Disposal Works Construction Pe it Now =_ Dated"`."./J_..__'��- ............. A , -•---------_ 5^__ _ Bo health DATE___ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS' a