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HomeMy WebLinkAbout0039 PATRIOT WAY - Health 39 Patriot Way Centerville P A = 192. 215 h No. 4210 1/3 ®RA �z 1000 6f ® � TOW/!t or B&RNSTABLE .LQCATiQI�i .J l r�o T __ SEWAGE#' IITALI.ER' QNE N4 SBF''I1C TANK CAFACf'I'X ` Gr�� LEACfIING:FACIiG�'fY't } Isle) NO.Og-g�y�Qa1+hS= - bUILOER OR'OWi�tE I PERA�ITIyATB CC3M3'T.fA.NCE DATE.' Separation Dtstance,Between Fbe FeeR Maxiatum Adlasted Crroondwnter Table tothe Bottom of Leaching Facility FgViiG ate siloply�►etl andLeadung Facility (5f any waits exist oa site ur antlun 20p fact df Itimog fw cy} Feet Edge o£ land andIeaclzing Faca'lty of any wetlands exist Feet withlin 3IX)'feer € caching faalrt3► . o ba 3 C7 r D 3" 3 .391 TOWN OF BARNSTABLE LOCATION `"I� 01�" SEWAGE # VMLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. MMJJ11 SEPTIC TANK CAPACITY ( 0j(q--A i LEACHING FACILITY: (type)" / OJI c) (size) NO.OF BEDROOMS Q- BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility)/�, i Feet Furnished by (1 �t QCA At S' t A � n � 3 A g 4 o � Cuti D ` 84 5� B D � 31 � 5° k TOWNh6oj— OF BARNSTABLE LOCATIOaqP&HOf SEWAGE # �5u �. _ VILLAGE ASSESSOR'S MAP -,&,'1/LOT INSTALLER'S NAME & PHONE NO.g&h 6&X1 77MwV SEPTIC TANK CAPACITY LEACHING FACILITY:(type) j (size) NO. OF BEDROOMS 3 PRIVATE WELL OR2UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r Y 9A6 J LOCATION SEWAGE PERMIT NO. GoT -/ TEAT/?ioT 1.ciA2' VILLAGE r INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER G/9111Do/Z DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r 317 y, R P, a.:: .. FRDNi No...L....' : s�✓ Fps..:? APPRik6 THE COMMONWEALTH OF MASSACHUSETTS rns BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuu fair Diripa iial Work.6 (fa mitruVnIndividual Prmit Application is hereby made for a Permit to Construct ( ) or Repair ( Sewage Disposal Sys t �, t /afi .. - ............... ner afJ �... . ... a 1 - ---... ------------------------------------------ l//s /� .... ! ----------------------------- ---- ----- - Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms._-_-__j .Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building -__________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures --------------------------------- •. W Design Flow............................................gallons per person per day. Total daily flow.._:s:,��v........................gallons. 1:4 Septic Tank—Liquid capacity/00 .gallons Length................ Width................ Diameter--.--.--..--.--. Depth................ Disposal Trench--No. .................... Vidth.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R'+ ............................................................................................................ •.... ----....-....----------........... .......... ODescription of Soil.............................._..---....------------------------------------------------•-------------•-------------.....---.........--••-------••...................--- x U ....-•••--------------------•--•---------....._......---••--•--•----------------------•--•-----•--•--------------•------------•------•-------------------•-•--------...................----------•...... x -------------------------------------------------------------------------------------------..................................---•----------------------. U N ure of Repairs ;lte o s Answer when applicable-��1.5 �_.._jo®®.�4—v&L:--� G� 07r.. ..... ---------------------------------------------------------------------------------------------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— he undersigned further a es not to place the system in operation until a Certificate of Compliance u by �ea Signed ...:............ .......... ....................................... ........ ..... ....... ........................................ Application Approved 115<5-. . ............. ... ..------------ Application Disapproved for the following reasons: ...... .. . .......................................... .................................................................. .... .................................................... . ............... ......... ..------------- .--- .----- ............................................................. ............ .......... .................. Date Permit No. ..... r�.......ZF ,t, .................... Issued ......... /.:... . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate of (gontlatianve THIS IS TO CERTIF"', That he In Sewage Disposal System constructed or Repaired .................... ......................I........ -----------------------------------------T1 -k�---- k------------ ------------------ by ................................ .............. I nsta Ile r ..... ............ .............. at ......................................... ........ -)/0 6........... -171 E f The State Environmental Code as described in has been installed in accordance with the provisions f**TI' ' the application for Disposal Works Construction Permit No. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .00 11 C ......................................... ........................ ----------- DATE......"-#.......0 ..............e-...........i� .....------------------------------ Inspector " ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.... TOWN OF BARNSTABLE FEE.. At75 ...................... Disposal Warks Tamitrudian ramit Permissionis hereby granted....... ........ ................T........................:.......................................................... to Construct or Repair (�an Indi"Vidu I $e�vage Dispbsal System at No............................ 7,74gyz,.6 2 M) MT/L", .................... ......................... ........................................................ Street as shown on the application for Disposal Works Construction Permit l i -::I���ated---- ............. -—---- ------ ............ . ..... .................................. Board of Health DATE---------------- 7 FORM 38508 HOBBS&WARREN,INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE v Appliration for Uirivwml Wnrlm Toastrnr#inn.-Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( . ) an Individual Sewage Disposal System at: - 1 ----- or.('o d-:\dd ss No k....�qq SY i /�/t-c -7,Llof:.. ` V� � t i��/� =...._.._ - ---- -------•-------------- /` Ofcncr 'dress a > .......---•----- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms.......... ......... .--..Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons.------............. ( ) ( )....... Showers — Cafeteria a' Other fixtures ............................ _ _ --•-----------------•------•-••-•-•------ WDesign Flow............................................gallons per person per day. Total daily flow----- ��.........................gallons. WSeptic Tank—Liquid capacity/`0(n.gallons Length._............. Width---------------- Diameter...----_--.-.-- Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..--...................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit......--............ Depth to ground water........................ LX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------------------------------•----•---------••------- ---•-------------------•-•--•--•----- 0 Description of Soil........................................................................................................................................................................ W U ...........................•----........--•---...........-•--------•----------•••••-----•---••------•---•-------••---•--•-•------•------•--------•----...--••---•--.._............---•---•-----•••-•---- W --•-----•-•----------------------------------------------------•..............----------•----••---------------------------------...---•----------------------•-- -- .............._...... U Nature f Repairs or Alterations—Answer when applicable..m S try..8----0 o - 6fal it ( (XCp /)/i : �``� /)/t`---�.f�!.----- ----�5�•-••------•-•---••-----•----•---••-------------------•-•-----------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance has-been-issued by the=boar-d£of heal<tK. Signed`_" ----- ..........................�.. ....��......!.. ........ I � ce Application Approved B.—..--........Ap__4 ?�.1------------------ -----........ .................. ,�`.�:� Dare Application Disapproved for the following reasons: ..--------------------------I -- ............................... ................................................. ........................... .. ... ..................................................._..................._......... . .. . --................................ ........................................ - Dace Permit No. ......t;1....s ..`::. ------- -------- Issued --------- ."°' �� . Dare _ _- C74) No.._.......r._......... Fim$..............:-........ THE COMMONWEALTH OF MASSACHUSETTS _�. BOARD OF HEALTH Appliration for Dispas al Works Tnnitrnr#ion Vernat Application is hereby made for a Permit to Construct k>�Q or Repair ( ) an Individual Sewage Disposal System at: 4�m Tem VI) le� ____--•-- ................ _................................. )ZLoc'a-tt"; Address (/•�� /'® � or Lot No. .... ....... ------6�Ld..... -_. tk ...__ Owner Address ...._- r y 1.�.� r_ - ..i lrx� k C 5 -------------------- Installer Address Type of Building Size Lot...14,) Sq* fept Dwelling—No, of Bedrooms.... .......... Attic ( Garbage Grinder ( /� aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( ) Q' Other fixtures ______________________________________________ W Design Flow:.......... ____.__ .............................gallons per person per day. Total daily flow--------�_:�O....................gallons. WSeptic Tank—Liquid capacity gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width ....... Total Length......... Total leaching area.............__ff_ sq. ft. Seepage Pit No.......i------------ Diameter___.r.Q."�__ Depth below inlet... __. Total leaching area_ _S�__sq. ft. Z Other Distribution box Dosing tank �i(�)� '-' Percolation Test Results Performed by--------- = �_ - - �_------ Date.......L- ..... Test Pit No. 1....... ___minutes per inch Depth of Test it.___1' ___- _ Depth to ground water_._i1 -.6........ Test Pit No. 2................minutes, er inch Depth of lTest Pit.................... Depth to ground water........................ ate_.._<_.S-UX350? ........... Description of Soil - .,-r--------��`kM 5�=--... ....................................................................................... 1 W ----------------- '7 --.-> -------4-- i�r ._.._ � 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 iI:L L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ss d by oard of aalth. • 1y ,, ate Application Approved By_____ __ Date Application Disapproved for the following reasons:.... .........................................................................................•-----..__..._.. ............................................•------------......----------........---•------•-•-•--..__._.._...----•------------------------------...---------------------•------------------•-•-•---••_.. Date Permit No............................... Issued_.... ---7 ' ................... Date aio THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........�.0.4 e! ..........OF....... ..- a le........................... f9rdifgratr of Toutplittgtrr THPqS TO CE T FY, That`the In 1 Sewage i 'po Sys em constructed or Repaired ( ) • � In ller C. _ ......................... has been installed in accordance with the provisions of TIT 5of The,State Sanitary Code as desc application for Disposal Works Construction Permit No----- ... __..... ....... dated �__ __ ---- .__. THE ISSUANCE OF THIS CERTIFICATE SHALT: NOT BE CONSTRUE® AS A`GUARANTEE THAT THE SYSTEM WJ L FUNCTION SATISFACTORY. 7 r DATE...... ............./ , ( yea--•-••------..................... Inspector..........�-• ......................... ....... r },; t THE COMMONWEALTH OF MASSACHUSETTS BOAR o. :Y ..... o F.... � ......................... N FEE.......::...:.:::....... Map Wore owitrt74.1su rrntt� Permission` is hereby granted • ... �_. � •-. __`Y.'.!-. ....._. ... r.... to Constr�t r pair ( ) an Individual Se�'�ie Disp al atNo................ . .... ._._.... t .. ........................... as shown on the application for Disposal Works Construction Pe No... .� _woard ted_.._ !._, Health .. • DATE---•--�`�"--�-�•' ..:..: FORM 1255 HOBBS & WARREN. INC., PUBLISHERS .,, No...._......�! 6' Fins... ......... THE COMMONWEALTH. OF MASSACHUSETTS BOARD OF HEALTH Appliratioll for Biipngal ]York i Tnnitrn.rtiun Vamit Application is hereby made for..a Permit to Construct kVQor Repair ( ) an Individual Sewage Disposal Syat: V Alt?.. .................. .... 7 - ............ Locati Address or Lqt No. Owner t Address 'r' ------ �c !.....Vjge r.>lVa r-u_Ink..0_7Ac ..... :. '� .. . Installer Address *+� U Type of Building Size Lot--j..1 JJ6,._..Sq. f 4 Dwelling—No. of Bedrooms...... ............Expansion Attic ( Garbage Grinder '4 Other—TYPe of Building --------•------------------- No. of persons............................ .Showers Cafeteria a Otherfixtures -----(-----) -- Design Flow.....................:...... .....__gallons per person per day.. Total daily flow..-... gallons WSeptic Tank—Liquid capacitvfgallons Length Width_ Diameter.:... Depth................ x Disposal Trench—No. ................... Width.. ..Total Length....... Y Total=leaching area... .._.._.. sq. ft. Seepage Pit No...___.�..........._: Diarrieter._.. ''.t .:_ Depth below iniet..6 "".40. Total leaching area.. sq. ft. Z Other'.Distribution box ()0 Dosing tank ( ) a Percolation Test Results Performed by...._.._q -y'c �_ &jkVX.;t...... Date............. ... ,-a Test Pit No. l........ ...minutes per inch Depth of Test' it.....IA."' Depth to ground water., 74 ..... Test Pit No. 2................minutes er inch Depth of Test Pit.................... Depth to ground water......................... x ~-z------- Q O Description of Soil............in.` t *'t'.. -----------••....... ..........•.-_-----••--......._...--.--•-•-•- x �? - ►rcd --------------- ------------------------ --1-�..CL....... .. •. --•••----••••-•------•--••-••-•-•••-•••--••-----••••••.........................-- UI Nature of Repairs or Alterations—Answer when applicable..,.:.:...............................................;............._........................... ---------------------------------------------------------------------------------------------------------------------•-------------------...-----•------------._.........•-••......................•... Agreement: The undersigned agrees to install the .aforedescribed Individual Sewage Disposal System in at•cordance with the provisions of TIT 5 of the State Sanitary Code The undersigned further agrees.not to place,•the system in ¢operation until a Certificate of Compliance has been ss d by Yeeoard of ealth i ne -. ..... 1.... ate Application Approved By..... x._ _ ` p t .. ........ ........... -'Date --- T " Application Disapproved for the following reasons-----........................................--------------------------------...---------••-••................. ......................................................-............................................................................................................................. ..................... Date PermitNo......................................................... Issued_....................................................... ' 41 pr y G 5" f; 13ac 6,X►�i N rt i�d c r {�eacA.Pif f /Ooo 9 LI + S e P f IC \ae,, 5,9� — --� , l 30,4. n 1 ZV VOT a {. S 2 r ,, Y ;t , Y SPOT Ox0 CERTIFIED PLOT PLAN EXISTINGf•., EXISTING CONTOUR - - 0zb� y �''/�>` L✓i y `FINISHED SROT- ELEVAT-L.ON 0 0 ,� fINtSHED CONTOUR 0. r \ APPROVED i BOARD OF HEALTHgAll "'I'STA9169 MASS _ DATE AGENT SCAT E y0 DATE :T� ` r'EL DREDGE. ENGINEERING CO. lNC , C L I E N ' we I CERTIFY THAT THE PROPOSE D.'..• riiEGISTEREC (�REGISTERED�) JOB N0. �� Icy BUILDING SHOWN ON THIS PLAN, �. CIVIL.. LAND yJ CONFORMS TO THE ZONING LAWS , L,ENGfNEERS-' �;.SURVEYQ~RS,J DR. BY � a OF RARNST BL MASS. iC YARMOI !'H,/M�x H'i 1NN!" M,a ': / ' SHEET- / OF ._ D eTE REG. LAND SURVEYOR t_ ...lie 20 PT. M/N. /Y07E %F EiTNER 7h1,ESFP7'1C 7AA1 Fm/T ARE ; } /o r //v. ® . "PVC PIPE sNALL ®.drr eR006"r. 7a O/?A®e:CANEXTRA htEAVY CA ST /R®/Y COAM3 ®"PL�iQ FT /FIN 'OR/V,-- W li y ORAOE CU CLEAN .SANG �• 6.4CxF/LL T- 1 '°' '• IRON P �' f ra4 .a. --'LAYER 'Cl/ U U LFAL. 0 • r o n,p o 0 • o.� M/N. P/TC/y -T. S,EPT/C T.4 MK ,D I ST. o A WA 5HF0 SMNE ® A 1 • A O o O O • 0 e m ry „ BOX o e IDo1 0a a o00r 314 \'i �:'oL. p r.,a• : :.�.,. .,.: - :.a. o ® ° r • o QEPTj/ ° e o D ® o WA39E0 STONE - o Q o 1 / / • ® ® p • • D o n o b a m c t r o e ® o ® ® o 1 D p c b y PRECA5 7 -jS-AG E /NV eXT &,-.EdVAT/DNS Y^/ �,r G� Q m► op a a o P/7 OR 5VL1/V /NIiERT AT BU/LD/NCr FT 6 � D/i4M. INLET SEPTIC 7-,4NK `_0- FT _Q_ FT. 01AA4. C SEE TABULATION, OUTLET SEPT/C T- V.A< 9 INLET,0j57R/f3UTYON BOX 9(/' AT. SECT/p/V OF GROUND W,47-ER TABLE OUTLETD/STR/B(!T/U/y BOX 'FY. Al FT. INLET LEACH/NG. P.1T , a FT, SE�tJA�GaE ®!a�'e® 'A L. .S'Y.STE/a�l 6 1.EAC H11V� �/T T.���JL.4T!®/ei SCALE %� _ /= ®'" U//LIENS/ON A DE3/CsN CR/TER/.�1 T. _ D/Af�ivs/o�v AF NUMOER OF ®-=,D.?OOMS 3 D/MENS/ON co )=T. ! G,4A?CA6ED/5P05A4 UN/T_' .S®IL LOG TOTAL EST/AjA-r-=D FLOW 3 G G.44.1QAY SOIL. TEST A/ SO/L 7ES7-#2 / Q NUMBER OF LL`ACH/NG: P/TS--- �C� I T 7 !`ELEd! �7� G �EL�d/ ®AT E OF SOIL TEST 1 h I S/OE LEACH/NG PEi� P/T —,547 FT. d 00TTom 4,64CH/NG PER P/T 7 FT G = RESULTS AV17'NES5ED BY K, TOTAL LEACHI/YG AREA t;c a.,, S46 PL`RCox` -r1o" RATS j*/ f e S S M/N�//NCH SQ, FT. P0iVC®LA770,V RA:r,=A&a a`` MN N/ .�/ CH RESER{�E LEACHING AREA _SQ. FT. 2/`> OF �y�J� ,y ROBERT -4 o P. Kis �7 a<'/• �3, o s ..d ssl9NA EN�'� �L:®� ���EJv�i �e 11VC. 7/2 AJA*N ST 3.'NO.MAIN ST." ' RYANn//3 ❑ NO G/�O!/ND WA7e.R- �A/COU/YTL�',eEO r I'9.as5 so`Yr9RM,G?vT.r,b,Ass. a C3 Cr/?O LINO r.,. ER JOB/VD. J G SHEET OF F Commonwealth of Massachusetts ; . Title 5 Official Inspection Form i5�l Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments y 39 Patriot Way Property Address Sandra Therrien r * Owner Owner's Name ,- `FI information is :X required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1.. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 Cityfrown State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 Eval by the Local Approving Authority �- 8-7-18 I spector's Signature Date The system inspector shall submit a copy of this inspection report'to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 C��6e a s Commonwealth of Massachusetts oo Title 5 Official Inspection Form 0,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r;+n' 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8J7-18 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i } ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IYI� 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are•repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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 ON ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ `Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form 'liCl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , vii,50 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts r� fw Title 5 Official Inspection .Form i i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 c � Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w: fit. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 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? ® ❑ Wasthe 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 II 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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town 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? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2018 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts A Title 5 Official Inspection Form li"I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped 8-7-18 Robert Our Was system pumped as part of the inspection? ® Yes ❑ No f yes, volume pumped: 1000 gal gallons How was Yp pumped um ed determined? Receipt q Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection Form f ''� i► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� ,r 39 Patriot Way J Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): 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: 1000 gal Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 1� 9 Title 5 Official Inspection Form '01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is Centerville MA 02632 8-7-18 required for every ' 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 20" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I I Commonwealth of Massachusetts .� Title 5 Official Inspection Form i I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 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 i nspecti on)(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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts y, Title 5 Official Inspection Form �1I-.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pits. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts ,y, Title 5 Official Inspection Form r� •I '11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal ❑ 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.): Pits in good condition with water level and stain line in pit numbered 4 at 24" belwo inlet invert. Pit numbered 5 was empty at inspection with no visible stain lines. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 L Commonwealth of Massachusetts j� Title 5 Official Inspection Form Ili Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 c Commonwealth of Massachusetts y Title 5 Official Inspection Form Zi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville - MA 02632 8-7-18 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 J CO) -- i d3 � } -39 II f�.�..+�`rlJ�.he�TYSyIYih7w/b,Y9alelM.eiaiBYilli.�l! ... .. p . 3 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r� rp Title 5 Official Inspection .Form ! iir Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 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: 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Sandra Therrien Owner Owner's Name information is required for every Centerville MA 02632 8-7-18 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1' Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information is Centerville MA 02632 Aril 27 2011 required for every p . page. Cityrrown 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 forms A. General Information on the computer, I I use only the tab 1. Inspector: key to move your use the return not David D. Coughanowr use the key. Name of Inspector Eco-Tech Environmental my Company Name 43 Triangle Circle Company Address Sandwich MA 02563 Cityrrown 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority April 27, 2011 e, 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. U /I t5ins•0901 Title 5 Official Inspection Forth:Subsurface Sewage Di I I System•Page 1 417 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information is required for every Centerville MA, 0.2632 April 27, 2011 page. citylrown State Zip Code Dateof Inspection B. Certification (cont) Inspection Summary: Check A,B,C,D or E/always contplete.all of Section D A) System Passes: 0 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 ind►cated below. Comments: Inspector's Note==> Aseptic 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 itwas inspected. No estimate.or guarantee of system longevity is.made or implied by passing determination. B) System Conditionally Passes: ❑ One or more system components.as described in the "Conditional Pass"section needto-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(whethermeial or not)is.structurally unsound, exhibits substantial infiltration_.or exfiltration or tank failure is imminent..System will pass inspection ifthe 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 ❑ NO (Explain below): I51ns•09108 Title 5 Official Inspection Form Subsurface Sewage Miposel:Syatem•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Add"ress Elizabeth T. Cook. Owner Owner's Name information is Centerville MA 02632 April 27, 2011 required for every R 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 pipes)or due to a broken,settled or uneven distribution box. System will pass inspection"if(with approval of Board of Health): ❑ broken pipes) 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)(0)`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 feetof a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system i Page 1 of 17 husetts Commonwealth of Massac Title 5 Official Inspection Form " Subsurfaceewage:Disposal System Form - Not forVoluntary Assessments,S a 39 Patt[dt Way Property Address Elizabeth T.Cook Owner Owner's Name information is Centerville MA 0263,2 April 27,2011 required for eery page. cityrrown State Zip Code. Date,of inspection B. Certification (cont.) 2. System will fail unless the B"oard of Health(And ftblic'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 aseptic. 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. DEF certified laboratory, for eolif&m bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal 7to or less'than 5 ppm, provided that no other'failurecriteria,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 ElBackup of sewage into facility or system.component due'to overloaded-or clogged`SAS or-cesspool Q- Discharge or ponding of effluent to the surface of the ground or surface waters due to an°overloaded or:clogged $AS or cesspool Z 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 oravailable volume is less than day flow. t5ins•0910B Tifle 5 Official Inspecliqn Form:Subsurface Sewage Disposal System•Pao 4 of 17' Commonwealth of Massachusetts luTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information is Centerville MA 02632 Aril 27, 2011 required for every p page. Cityrrown 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 t 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 I I 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•09= rile 6 Official inspection Forth:Subsudace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts MsTitle 5 offical inspection For Subsurface Sewage.Disposal:;System Form-.Not forVoluntary Assessments N 39 Patriot Way Property Address Elizabeth T. Coo_k Owner Owner's Name information is Centerville MA 02632 A nl 27 2011 required for every. p 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 Z ❑ 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? El 0 Has,the system received normal flows In the previous wo week period? El Q Have large volumes of water been introduced to the,System.recently or as part of this inspection? ❑ Were as builtpla,nsT of the system obtained and.examined? (If they were not available note as N/A) t ❑ ❑ Was the facility,or dwelling inspected for.signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? X❑ ❑ Were all system components, excluding the SAS, located on site? Were:theseptictank.manholes uncovered, opened,,and the interiorofthe tank. inspected for the condition.of the;baffles or tees, material of construction,. dimensions, depth of liquid, depth of slud'ge.and.depth:.of'scum? Z ❑ Was the facility owner(and;occupants if different from owner);provided With information;o.n 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)a D. System fnformation Residential Flow'Conditions: 3 2 Number of bedrooms (design): Number of bedrooms;(actual): DESIGN flowbased on 310 CMR 15.203(for example: 110 gpd.x#of'bedrooms) . 330 gpd t5ins•09108: Title S Official Inspection form:Submfaco Sewago'Oisposal system•Page of Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name- information is Centerville MA 02632 Ap ril 27 201.1 required-for every � , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑X No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ED No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available.(last2 years:usage.(gpd)): 155 gpd Detail: 2009-2010 Sump pump? ❑ Yes ® No Last date of occupancy: 6 months agoDate 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: t5insi 09108 Title 5.0fficial Inspection Form:Subsurface Sewage:.Disposal System•Page or17 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form: N,o.t for Voluntary Assessments, 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name required f r e Centerville MA 02632 Aril 2T 2011 required for every - - April page. 'Citylrown 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 d copy'.of latest inspection of the I/A"system oy system operator under contract Tight tank. Attach a copy.of the DEP approval:. Other(describe); t5ins•09/08' T tleS�Otfciaflnveaion Form:Subsurface Sewap Disposal'System+P..age.8 of i7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information is Centerville MA 02632 Aril 27, 20"11 required.for every p page, City/Town State Zip Code Date of Inspection D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: Age 17+ years. Certificate of Compliance for new leach pit dated 11/1/93 (permit 93-588). Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron R 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of'leakage, etc.); Sewer line appears.structurally sound:with no evidence of leakage or backup into dwelling. Septic Tank(locate,on site plan): Depth below grade: 1 feet Material of construction: 0 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 certifcate) ❑ Yes ❑ No Dimensions:. 8'.5ftx6ftx5ft(1000gal) Sludge depth:. 8 in: 15ins,•-09108 Title Official,Inspection Form:Subsurface Sawa©o Disposal System•Rage 9,of 17 . Commonwealth of Vassachus4 tS Title 5 Official Insp:ectio-n Form Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments . — 39 Patriot Way- Property Address Elizabeth T. Cook Owner Owner's Name information is. required for;every Centerville; MA 02632 aril 27, 2011 page, cityrrown State Zip,C;o'de Dale of Inspection: D: system, Information (cunt.) Septic Tank (cont,) Distance from top of sludge to bottom of outlet-tee or baffle 26 in Scum thickness 2.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 13 in How were dimensions determined? Previous inspection report 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 is not required at this time but maintenance pumping is recommended within and.every two years..Tank appears 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-.- El concrete ❑ metal ❑fiberglass ❑polyethylene El.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+09108 Titles Offi6al,inspectionform:Subsuitaco Sewage DisposilSyMem-Page10'of 17 Corntnonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments .39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information is Centerville MA 02632 Aril 27, 2011 required for every p page. CitylTown 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: bate .Comments (condition of alarm and float switches, etc,):, I Attach.copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No, l5ins':09/pg' Title 5'Official Inspection Form;subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts I . Title 5 Official Inspection Form _l Subsurface Sewage;Dis.posal System Form -Not'for'Vo.luntary Assessments w 39 Patriot Way Property Address Elizabeth T. Cook Owner ,Owner's Name information is Centerville. MA 02632. Aril 27 2011 required for every page Clty/rown state Zip Code Date of Inspection D. System Information (cont,;j 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 structurally sound.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: Q Yes E No Comments.(note condition of pump chamber, condition of pumps and appurtenances, etc.). I SON:Absorption System.(SAS) (locate on site plan, excavation not required): If SAS not located, explain why:" t5ins-09I08 Title 50ficial Inspection form:Subsurface Sewage 0isposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Patriot Way. Property Address Elizabeth T. Cook Owner Owner's.Name information is _ Centerville MA 02632 April 27 required.for every p �il ,2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 2 El 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, signsof hydraulic failure, level of`ponding, damp soil, condition of vegetation, etc.): Soils above leaching pits appear unsaturated;.No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was.observed. Second leach pit was uncovered and found to be dry. No staining at cover interface or in overlying soils was 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 f6tnie'd19f08: Title 5Oficial Inspection Form:Subsurface Sewage Disposal System•Page.13of17. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owners Name information is Centerville MA 02632 Aril 27, 2011 required for every A page. Cityrrown 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.): 15ins•09108 Tille 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 39 Patriot Way Property Address Elizabeth T: Cook Owner Owner's Name information is Centerville required for every MA 02632 April 27,2011 page. City/Town ;State Zip Code Date of Inspection' D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system;including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ? A T CT WAY -22 Al- s (J r (L v 50T< D-PDX L-1 Z t5ins!09/08 Tlile 5 Official Inspection Foim:`Subsurface Sewagebisposat System>-Page 15 of 17' Commonwealth of Massachusetts Awg Tittle 5 Official Inspection Form. Subsurface Sewage,Disposal System Form-Not for Voluntary Assessments 39.Patriot Way. Property Address Elizabeth T. Cook Owner Owner's Name information is required for every Centerville veryCenterville MA 02632 April ril 27, 201`1 page. ckyrrown State: Zip Code; Date of Inspecfibn D. System Information (cont) Site Exam: Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: .12 ft feet Please indicate all methods used toAetermine the high ground water elevation: ❑ Obtained:from system design plans on record. If checked; date of design plan reviewed: 12/1L04 Date ❑ Observed site (abutting"pro'perty/observation hole within 150 feet of SAS) 0 Checked with.local Boardi of Health =explain: Previous inspection report Checked with local excavators; installers-(attach documentation)' Accessed USGS.database explain: You.must describe_how you established the high ground water elevation: Previous inspection report used hand auguring to determine that high groundwater is below 12 fleet. Before filing this Inspection Report,"please see Report Completeness Checklist on nextpage.. 5ins•69M Thle 5 Official Inspection Form:Subsurface Sewage Disposal System c Page 16'of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Patriot Way Property Address Elizabeth T. Cook Owner Owner's Name information Is Centerville MA 02632 Aril 27, 2011 required for every P page. Citylrown 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-09108 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS z w DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM t PART A FRECEIVED CERTIFICATION Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 IYI�.p q ZW4002 Owner's Name: BRENDA GOSTANIAN Owner's Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 ARNSTABLE H DEPT: Date of inspection: 5/27/02 Name of Inspector: (please print) JOHN GRACI Company Name: .i aI SEPTIC(INSPECTIONS,101 19 Z� Mailing Address: Pb, BOX 2119 TEATICKET, MA. 02536 MAP 1 PARCEL • 1 5 Telephone Number: 508-564-6813;f A, 508-564-7270 '. LOT 4'- CERTIFICATION STATEMENT 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 andtmaintenance 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: X Passes` ' _ Conditionally Pa ses _ Needs Furthe aluation by the Local Approving Authority Fails INInspector's Signature: Date: 5/27/02 The system inspector shall submit a opy 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 sWf 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. Notes and Comments ;= '£a. ' f SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL''LIFE. RECOMMEND RAISING COVERS. ****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. .t T{I� C 1++c,�nrtinn Fnrm 6i1�,/Mo n +'t t ' Page 2 of I I OFFICIAL INSPECTION`FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,, ,CERTIFICATION (continued) Property Address: 39 PATRIOT WAY CENTERVILLE,MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND RAISING COVERS. 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 of repair,k,:as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)`in the for the following statements. If"not determined"please explain. n/a 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 exfltration 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. ND explain: n/a n/a 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 _ obstruction is removed a. _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken,,pipe(s)are replaced _obstruction is removed ND explain: n/a ;t Page 3 of 11 ik OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 PATRIOTI-WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN.,, , , Date of Inspection: 5/27/02 C. Further Evaluation is Required by the Board of Health: t, - l k 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 ,i. 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. N.; _ 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`tanl'an'd SAS4and 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 n/a "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a ;1 i t; ;t Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No I ' X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool .• X Static liquid level in the'di'stribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy isiwithin a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is,less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that,facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma 1 1 (Yes/No)The system fails. f have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system failsfi 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. You must indicate either"yes"or".nod to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet,of a surface drinking water supply X the system is within 200 feet of a trib,utary to a surface drinking water supply X 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 tailed. The owner or operator of any large system cousirlered 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. 4 , Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 A I Check if the following have been don'e'You must indicate "yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? _ X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(if they were Licit available note as N/A) X _ Was the facility or'dwelling inspected for signs of sewage back up? ;+ F X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ 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 '? X _ Was the facility owner j(and occupants if different from owner)provided with information on the proper maintenance ,;., of subsurface sewage disposal systems The size and location of the Soii'Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] r{ itL �i G r R Page 6 of I I OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 PATRIOT WAY CENTERVILLE,MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 9 of bedrooms):220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system.(yes or:no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd#AA Z(� 100-0 Sump pump(yes or no): NO Last date of occupancy: n/a i i UoU COMMERCIAL/INDUSTRIAL Type of establishment: n/a "1'>' Design flow(based on 310 CMR,1 :203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a ,. GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the..inspection(yes or no): NO If yes,volume pumped: n/agallons-- blow was,quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the`DEEP approval Other(describe): n/a 1. Approximate age of all components,date installed(if known)and source of information: 1979 BY AGENT Were sewage odors detected when arriving,at the site(yes or no): NO 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 BUILDING SEWER(locate on"site plan) Depth below grade: 18" Materials of construction:_cast iron',_40 PVCXother(explain): 20 PVC Distance from private water supply well or suction liner n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER h� SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W=40 .1011 " Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW'AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. RECOMMEND RAISING'COVERS. GREASE TRAP:_(locate on site plan) Depth below grade: n/a ' " Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations;.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a u 7 Page 8 of I I � = t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 PATRIOT WAV CENTERVILLE,MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 TIGHT or HOLDING TANK:' (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons w• Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a e, ri'a DISTRIBUTION BOX:X(if presentmust be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenanceE, etc.): n/a . 1 R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs'of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. PIT HAD V IN IT AT TIME OF INSPECTION AND STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN T OF LIQUID IN IT.,RECOMMEND RAISING COVERS. BOTTOM IS AT 9'. CESSPOOLS: (cesspool mufst be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) .01 Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signslof hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 11 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION(continued) Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. NCk oB p C /n� NA D A< 31 AD 0 3� in Page 1 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 PATRIOT WAY CENTERVILLE, MA 02632 Owner: BRENDA GOSTANIAN Date of Inspection: 5/27/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators;installers-(attach documentation) NO Accessed USGS database-explaidn m/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. II 04 Jolul Giaci D.E.P. Title V Septic Inspector - _564-6813 SUBSURFACE 8EWAGE DISPOSAL SYSTEM INSPECTION RM Address of property . 31 %O� Qn Owner's- name Date of Inspection PART A - CHECKLIST Check if the following have been done: Ll Pumping information was requested of the owner,- occupant, and- Board of Health. None of the -system components have been pumped for at least two-weeks - and the system has been receiving normal flow rates- during that period. Large volumes_ of water have not been introduced -into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. , The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of ,baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on exist: ng information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner)) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM - y PART B SYSTEM 'INFORMATION - _ FLOW CONDITIONS - If residential fnumber of bedrooms - number of current residents garbage grinder.; -yes-_or no tslaundry connected to system, yes or no - seasonal use, yes ..or no. _ If -nonresidential, calculated flow: Water meter readings, -if available: J ,doo Last date of occupancy GENERAL INFORMATION Pumping records and source of information: A/Z System pumped as part of inspection if yes, volume pumped yes or no 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL BYBTEM INSPECTION FORM u PART 8 SYSTEM INPORKATION Continued SEPT-IC TANK: - _(.locate on .site plan) depth -below gradei material. of` construction: concrete metal _FRP -other(explain) .dimensions: sludge depth - �" distance from top of sludge to- bottom of outlet tee or-baffle scum thickness- - b" distance from top of scum to top of outlet tee -or baffle distance from bottom of scum to- bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in:-relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) s S�eA i 1 v be IIA,'A WA06 eVeN DISTRIBUTION BOX: 5 (locate on site plan) C el �4, �oF6e depth of liquid level above outlet invert Comments: (note if level. and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances;;: recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM— INSPECTION FORK s s PART 8 — . SYSTEM INFORMATION oontinned SOIL .ABSORPTION SYSTEM, (SAS) :_ — — Jlocate on site plan, if possible; excavation not required, but may be . approximated by non-intrusive methods) - If not determined to be present, explain: ' Type - leaching pits and number ,flew leaching chambers and number leaching galleries and number - leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition. of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) 4 SUBSURFACE -SEWAGE DISPOSAL SYSTEM IRSPECTION FORM a PART B - _.SYSTEM INFORMATION-continueC _-- SKETCH';OF SEWAGE . DISPOSAL SYSTEM: - - include .ties to at least .two permanent references landmarks or benchmarks locate al wells-within 100 ' N� 3`� 1 D o kw ovev_� RC z15 AD 3J'L" ga W g tR 3� B� s0 e 6� �h DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: F SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C _ < FAILURE CRITERIA- - A Indicate yes, no, or not determined (Y; N, or ND) . Describe basis---of - determination in -all instances. - If "not determined", e:*plain why_ not) NBackup of sewage into facility? - Discharge or ponding of effluent to the surface of the round or surface waters? - g Static liquid level in the distribution box above outlet- invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? � Is any portion of the SAS cesspool o r privy: . below the high groundwater elevation? 1 V within 50 feet of a surface water? /V within 100 feet of a surface water supply or tributary to a surface water supply? �V within a Zone I of a public well? . within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not, the SAS) ? within 50 feet of a private water supply well? . less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM - - - - PART D — CERTIFICATION -Name of Inspector - Company Name JOHN GRACI Title I Inspector Company Address - P.O:-Box 2119 Teaticket, MA 02536 Certification Statement I certify that _I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete- as of the time of inspection. The inspection was . performed and any recommendations regarding upgrade, -maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Cheek one: V I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR ,15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 .CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date Ev < Original to system owner Copies to: Buyer (if applicable) Approving authority 4.. TOWN OF BOARD OF HEALTH S11I3SURFACF SEWAGE DISPOSAL SYSTEM INSPE.CTI.ON FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP , BLOCK AND PARCEL # �a OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR - Title Q Inspector COMPANY NAME - Teaticket, MA 02536 COMPANY ADDRESS Street Town ar City State LIP _ COMPANY TELEPHONE FAX ( 1 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : stem PASSED. The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED$ The inspection which T have conducted has found that the system fails to nrot.ect the public health and the environment in accordance with "'- t1� 310 CMR 1� . 30:3 , and as specifically noted on °ART C - FAILURE CRITERIA of this inspe tion orm . �L. Date Inspector Signature / J One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 . 305 partd.doc P4 r� �� \c�sIL �� ������ .� u��L��� �- �c��s�� �,