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HomeMy WebLinkAbout0083 PATRIOT WAY - Health 83 Patriot Way Centerville P A = 192 220 0%rford, NO. 1521/3 ORA ►:� 10% I ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ; M 83 Patriot Way Property Address r Holmes Owner Owner's Name information is Centerville Ma 02632 8/12/19:- required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return key. Company Name P.O.Box 151 I�11 Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection pwas performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. 0 Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Z::�r 8/12/19 Inspecto Signature Date The system inspect shall mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)wi In 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I" Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owners Name information is required for every Centerville Ma 02632 8/12/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 2) 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): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments II �, 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):. ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts n Title 5 Official Inspection Form I- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® 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 1/z day flow Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® q P P 9 Y 99 obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. An portion of cesspool or privy is within 100 feet of a surface water supply or Y P P P Y PP ❑ ® Y tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form '? Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health- El ® 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 the were not p Y® ❑ ( Y available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 min Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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.): Crease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner pumped 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): - Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 216"feet Material of construction:. ❑ cast.iron. ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8112/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H10 tees in place risers on inlet and outlet If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" 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 18"tape and sludge stick How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place no major decay risers in place pump tank in 2020 for maintenance under normal use t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is. required for every Centerville Ma 02632 8/12/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot a of Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 Y evidence of leakage into or out of box, etc.): Dbox is solid. Camera inspected due to ve itiation growth in area of Dbox no major carry overs t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface 8ewage Disposal System-Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in workingorder: * El ❑ 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1)6'x6' precast ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,,�;p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching pit cover opened current water level is 12" below invert to pit and 18" below top of pit 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts rn - 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a M 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 . page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 Y1 V� I may A ° o � L/ t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts r� p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owner's Name information is required for every Centerville Ma 02632 8/12/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 38 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: town GIS mapping lot el. 70 You must describe how you established the high ground water elevation: low in area the lake el. 32 bottom of SAS 9' below grade 28'feet of seperation from bottom of SAS to GM Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts i - Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Patriot Way Property Address Holmes Owner Owners Name information is required for every Centerville Ma 02632 8/12/19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 01"� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Patriots Way M Property Address John Manley and Erin Govoni ' Owner Owner's Name l information is ■ required for every Centerville MA 02632 December 4, 2014 page. City/Town State Zip Code Date of Inspection � Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: ��U key to move your VVV cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority December 4, 2014 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. ( 1 l5ins-3/13 Title 5 Official Inspection Fo :S b urface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4 2014 page. City/Town State Zip Code Date of Inspection B. Certification Cont. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health � )1 ) Y 9 p 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is Centerville MA 02632 December 4, 2014 required for every page. CitylTown 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 '/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes' or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes' to any question in Section E the system is considered a significant threat, or answered "yes' in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. City/Town State Zip Code Date of Inspection .D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2013; 36,000 gallons and 2012; 42,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Patriots Way M Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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: Compliance issued September 16, 2010 for Leaching pit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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 Typical Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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 47" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? - Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. PVC tee in place. Depth of tank is 25 inches below grade. There is a riser within 10 inches of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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 effluent level with 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.): No evidence of solids carryover. Utilized camera to observe d-box. 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: (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 83 Patriots Way Property Address p y John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There approx. 4 feet of standing effluent in the leaching pit with no indiction of staining above the observed level. There is approx. 1.5 feet of effective leaching remaining in the leach pit. Leach pit is 33 inches below grade. There is a riser within 6 inches of grade. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is MA 02632 December 4, 2014 required for every Centerville page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 1 P 9 9 feet Estimated depth to high round water: 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: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Patriots Way Property Address John Manley and Erin Govoni Owner Owner's Name information is required for every Centerville MA 02632 December 4, 2014 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist j ® Inspection Summary: A, B, C, D, or E checked j ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BA..RNSTABLE LOCATION �' 3 &/,62ic_ 0,1/ -SEWAGE N e70/0'3551 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. C. S6b-276.cyc a SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /yo< �/o L<A.h�r� (size) Erg NO.OF BEDROOMS rJ,ne OWNER r!c• G. G PERMIT DATE: COMPLIANCE DATE: I d Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY � lnrcr U<drooNt 4+ )y' 4-3 0 0 ?I. 1 a 3 16 http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=192220&seq=2 12/4/2014 TOWN OF BARNSTABLE LOCATION 153 JT 0.gV SEWAGE# a0f0 VILLAGE Ce„ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. L. C. S6f^ 77G• ayc D SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /vim v T„�/�„C (size) C14 ` NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: to Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY —. Fi re bed om 971 o O O a a' i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for aigonl *pttem Construction permit Application for a Permit to Construct( ) RepairNo Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. � P4 64;�;9)YU6 ` Owner's Name,Address,and Tel.No. �jree LLc. SO 77G•GNG6 Assessor's Map/Parcel z c��# L t orb- d 77�1-8 3G�-Gyo/ Installer's N Ad ss, J T,eJ�V Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms f.-Z Lot Size `o t 4 I' sq. ft. Garbage Grinder ( ) Other Type of Building ' ,r A No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided J3C7 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �„/& Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (I A t 1et4 'a 4 o!k a n,c OA I A Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by is Board of Health. Sign d Date Application Approved by Date Application Disapproved by: Date for the following reasons 0511 Permit No. Date Issued A29_-36 r No. Fee ✓' —9-0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZI,pPrication for Mioo!gal *paem Cow6tructio'n 30ermit Application for a Permit to Construct( ) Repair Upgrade(``) Abandon( ) ❑Complete System l El individual Components Location Address or Lot No. 83 �k)4 Y Owner's Name,Address,and Tel.No. Assessor's Map/Parcel l yam+ " '�"" �7"'"" K✓c Lt"c— 508 776•L V 6 6 /0,4L e�+� 4 c A b-1,I Installer's N�{ne,Addr-ess, 1�., 77y-&3&-6yd/Tel NO Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms f 2 Lot Size t i sq. ft. Garbage Grinder ( ) Other Type of Buildingt,s (a No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �,�j gpd Design flow provided 3/j gpd Plan Date Number of sheets Revision Date Title s, Size of Septic Tank /oo,�r r A Type of S.A.S. Description of Soil l Nature of Repairs or Alterations(Answer when applicable) t / Date last inspected: `Agreement: W. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe a Date Application Approved by ` Date Application Disapproved by: \. Date t for the following reasons Permit No. SIOE")— Date Issued _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired-<�) Upgraded ( ) Abandoned( )by A• 9111<1e.- R.L. C at 17G4rid� has been constructed in acc dance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer �, C, Designer #bedrooms n Approved design flops gpd The issuance of t 's pe it shall not be construed as a guarantee that the system wi 1 funV�01� as des ned. g Yg Date � Inspector !- a� T. -. l: .,k �• ..art- yt_T ____---_-__ j .... �5 / Fee THE COMMONWEALTH OF MASSACHUSETTS , PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migoal *pgtem Construction permit Permission is hereby granted to Construct ( ) Repair,(:)—) Upgrade ( ) Abandon ( ) System located at pj_� •„71�,u S' uc,4. C M 4en 'd< and as described in the above Application,for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construct• n must be completed within three years of the date of this permit. Date I Approved by _ , Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information When (1 �� forms on the J' computer,use 1. Inspector: only the tab key to move your Michael McDowell cursor-do not use the return Name of Inspector key. The Building Inspector of America Company Name 2 Brookside Circle Company Address Wilbraham MA 01095 fed0" City/Town State Zip Code 800-626-4408 156 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails wA --4 ❑ Needs Further Evaluation by the Local Approving Authority October 29, 2009 Inspector's Signature Michael McDowell/mjl Date The system inspector shall submit a copy of this inspection report to the Approving Autho#y(Brb%rd of Health or DEP) within 30 days of completing this inspection. If the system Is a shared Mtem 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. � it D� t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Patriot Way Property Address H_UD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Centerville MA 02632 October 29 2009 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: WA ❑ 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: 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, exl brts'substantial infiltration or iexfiltra"tion or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM ,•''� 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Centerville MA 02632 October 29 2009 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑N Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑N The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will Dass inspection if (with aoDroval 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: N/A ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged.SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ WA Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ WA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ WA Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ WA Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ N/A 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. WA 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? WA ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 182 gpd 9 ( Y 9 (gpd)): Detail: 2008: 47,000 gallons; 2007: 86,000 gallons to total 133,000 gallons divided by 730 days which equals 182 gallons per day. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: WA Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Centerville MA 02632 October 29 2009 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown, None at Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 83 Patriot Way Property Address H_UD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic system appears to be original with house, approximately 30 years old, based on materials used and their condition. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 inchesfeet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20 feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer exits rear foundation wall 11 feet 8 inches in from right rear corner. Septic Tank(locate on site plan): Depth below grade: 20 inches feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'Lx5'Wx5'D, Approx. 1000 gallons Sludge depth: 2 inches t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 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 WA Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle WA Distance from bottom of scum to bottom of outlet tee or baffle WA How were dimensions determined? With a tape measure and pole Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Fluid level is not correct. Fluid level was 11 inches below outlet invert. Therefore N/A ratings are given above. Septic tank exhibits substantial exfiltration. Recommend replacement of septic tank. Observed small roots growing into septic tank. Recommend installing,risers to within 6 inches of grade. Recommend pumping septic tank every 3 years. Grease Trap (locate on site plan): WA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 83 Patriot Way Property Address H_UD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every 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.): Fluid level was correct, that is, equal with outlet invert (1). There was no evidence of solids carryover. Distribution box is level. Top of distribution box is 40 inches below grade. Suggest installing a riser to within 6 inches of grade due to excessive depth of distribution box. Pump Chamber(locate on site plan): WA Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is Centerville MA 02632 October 29 2009 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One ❑ 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.): There was no evidence of hydraulic failure. Note:The house is vacant and all utilities are off. The septic system has not been receiving normal daily flows for an unknown length of time. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/OB Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every 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 Sketch is not to scale ❑ drawing attached separately D C G =Inlet cover on septic tank B=Outlet cover on septic tank C=Distribution box D=Cesspool =26'0" YA=24'0" B=227' YB=27'8" C=20'6" YC=37'4" D=30'0" YD=57'0" ZZ Wag t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °wM 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 7 plus feet 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: Grade falls off greatly to rear of property. Basement concrete slab floor is approximately 7 feet below grade. There is no evidence of chronic water penetration in basement. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 83 Patriot Way Property Address HUD/Cityside Management Corp. 22 Medallion Center Greely Street, Suite 5, Merrimack, NH 03054 Owner Owner's Name information is required for Centerville MA 02632 October 29, 2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file The Board of Health for this town offers information on their website in which I have obtained a copy of an as built for this property. There are no other records. There is a$25.00 review fee and you have to be registered with the Town of Barnstable in order to conduct Title 5 Septic System Inspection, which we are. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE_Q=1 ASSESSOR'S MAP & LOT 'l LIZ 2_20 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ` (size) yJ io NO. OF BEDROOMS BUILDER OR OWNER `> �l{��° �82he PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) - Feet Furnished by �C�I o lit O�Z�(oz 11 f-0 CAaL es a a ', Sp 3a LOCATION SEWAGE PERMIT NO. V1'LL/AGE L e) 9 Rio r!.�'.�I C'ogwr— C L INSTALLER'S NAME i ADDRESS 8 U I L D E R OR OWNER DATE PERMIT ISSUED 7 DATE COMPLIANCE ISSUED -3 -,2 -7 30 oAJ No.......:3�._....... _ Fizz.......;2........ r THE COMMONWEALTH OF MASSACHUSETTS e93 BOAR OF HEALTH D ............,.-�SW.A)........OF....... !-? ......... Appliration for Uhivosa1 Works Tomitrnrtiun Errant Application is hereby made for a Permit to Construct � or Repair ( ) an Individual Sewage Disposal System at: ........Q 1.�--------------------► P ' ....................................... L.c.a Address or Lot No. .._... �T!�� i� .�-da:.....---•-• 1 ..� �,�..p ..:.........•..... O er Address a �� •---•-1:: . .! . 5� -------------- ----------•----... Y 1 �1..1. ... . .? .:.. Installer Address U Type of Building Size Lot...1 i.�.Y&kLSq. feet `-� Dwelling—No. of Bedrooms...............��._.._.........___.__..Expansion Attic ( Garbage Grinder ( ) Other—Type T e 'of Building _...... No. of persons............................ Showers P, yP g -------------•------- P ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------•-•-- W Design Flow............................................gallons per person per day. Total daily flow........ ...................gallons. WSeptic Tank—Liquid capacity) gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........I......... Diameter...1.0_.:-U_. Depth below inlet.............. Total leaching area.... ,..sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.......LijbREb(7li----r-ZA)..... Date.......�...k.M� Test Pit No. I....��_._-_......minufes per inch Depth of Test Pit.__2._-.6_.. Depth to ground water..,.®. .: Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......._................ a ......... -- ..................................... 0 Description of Soil------• - �rm....._�..sm_ .Se?j L x -' N Ej- ............. UW -------•-• = i 2--------- �....-------------------------------------------------------------------------------- Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. ----------------------------•--------------•----•-•------•-•--......---•------•-----.................----.....----------------------.....-----------------------------------------------................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLE 5 of the State Sanitary Code—The undersigned Arther agrees not to place the system in operation until a Certificate of Compliance has bee is ed by�oard of iealth. C� Si ed.. r - ,-� ^ Date Application Approved By....... . . .. - ......I...... ---- Date Application Disapproved for the following reasons:..................................................................................--•......................... .............................................................•---•--.....-----------....---•--------------•----•----------•-••-•--•-•-----•-•---......•----•-••-----------------••...------•---------•-. Date PermitNo......................................................... Issued.•-�.---2.11........................... No.......3............ Fics.....�� S7..".. THE COMMONWEALTH OF MASSACHUSETTS F BOARP OF HEALTH .......... Cdt�.....�t. OF � - Ap iration for Diopos al Works Tonitrnr#ion ramit Application is hereby made for a Permit to Construct >d or.Repair ( ) an Individual Sewage Disposal System at: -- ................................... Loca'oa�- dress �y �}�+�- f� orr Lot No. ..... .r ...... 'S !4.J�:k.---1-i1o�4 emu. ........... lJea !. .]( 1_rt............. j - ,a ----------- ---..�UN7. :1 :.....:.:.. �r�'J' 1U/V iAddre5�' ,.t .............. w ---- " Installer Address / U Typeof Building No, of Bedrooms................ Size Lot-.16_�.A! ..Sq. feet Dwelling— . ......................Expansion Attic '' Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ...-----•----------------------•-•-•-----------.....---•----......--------...---------•----••----------•---••-----------•------......----......-•---- W Design Flow............................ ..... gallons per person per day: Total daily flow......, gallons. WSeptic Tank—Liquid capacit} gallons Length ............... Width= ... Diameter..... ......... Depth ............. x Disposal Trench—No..... ... ........ Width_.j Total Length .._ Total leaching area... ....._..`_ sq. ft. . Seepage Pit No..........I......... Diameter.. :Q.' 0... Depth below inlet......4 ........ Total leaching area. sq. ft. Z Other Distribution box ' Dosmg.ta aPercolation Test Results Performed by j .° .... E ---_.. Date. .Y. ".s-H...V Test Pit No. I...2.4...___minutes per inch Depth of Test Pit...1.2.!t45.. Depth to ground water.. bA.3., Test Pit No. 2................minutes per inch ,Depth of Test,Pit.................... Depth to ground•water.............:.......... .......... X---- .---- .......................... --------•-•----------------- ........ -Y 1ZO Description of Soil........ 11__ ---------------------------------------------------------------------------•--•-5, UW -----•........ ..................... . ........ Nature of Repairs or Alterations—Answer when applicable................................................................................................. ----------------••----------•------.: ..--•--------•-•------•----------•----------......•---------........--------------------------•-•---•---------••-•......---------•----•-----•---......•----.----- Agreement The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of LI':IE 5 of the State Sanitary Code— The undersigned rther agrees not to place the system in operation until a Certificate of Compliance hakbei y t board o iealth. S ed / •. Date Application Appr� ed By--.__ f ....../:n.i/� r:79'a..... Date Application Disapproved for the following reasons:......... -= _ ............................................•---._...------.......---......------...........-•-------•--.--..........---•-------------•-----•---••-----------•---------•-----_------------------•----•--- • Date PermitNo........................................................ Issued---------•----•------------------- .:...:.:... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. „t�A)....0 F.......... y r '+s� :�,,,�,,.,a,,.................... (9,rdifiratr of TompliFanrr THIS IS 0 CERTIFY, That he Individu 1 Se -zge Disposal System constructed„ ,"'�or. Repatred ( ) by----------------- �-,� .... . -.,C .n ` .. �, .... .._.1-------- f_ �_441 Instal er .:. has,been installed in accordance with the provisions o - of The State Sanitary Code.as described in the application for Disposal Works Construction Permit No.�r✓__._.....�................. dated_.... ". _'_7.?...... THE ISSUANCE &F THIS CERTIFICATE, SHALLMOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WN.I. FUNCTION..SATISFACTORY. : �i DATE................................................:............... Inspector.,..._.. - ---, -- ------....•. --- --------••-•--• THE COMMONWEALTH OF:MASSACHUSETTS BOARD OF HEALTH t rl .�► No......`............................ FEE....'r'�.......;; ...... �t��rosatl �� �on�#rnr#ion rrmit Permiss>on is hereby granted.. .....::....--•-•--- to Constructor Repair ) arLInu,ividual Sewa e Disposal System Street as shown on the application for Disposal Works Construction Pit No.. . .._.. Dated..... f'_ f.- 9'............. - ��ii ��' .......I 7L DATE. Board of Healt . FORM 1255 HOBBS & WARREN. I'IC.. PUBLISHERS , jdi ({p r ks1, u41 IV �? � � R 4 O r �r T0s1 +k r i in{/ r� F. a ,{` " �j. v��io • �f �_ j'./. x��Q 1 T .!{ 0 , -4c-N,P' 1` 1000 GAL u_ ;i 35' ov OF , d rr)' i j" ' �dryf£s i,.3.� .Y- `',d •, `'. f '! 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BY '4 '4 _ _ OF (BARNST BLE , MP 3. ' 'hl !hf F ' II •, MAIN ST .� . 712 MAIN ST. CH. BY• I� '� • �/ � ' 'Y .RMQUTH{ MASS. H�4NNIS, MASS / Z . SHEET—" OF DMA. E R G. LAND SURVEYOR W A?' -K IM'Ab 0� "CAT 'Z.-- JFO ITT.. MIN. 47W A N, '4 ASXrA'A' .0"Ovc Pjpz :i S.r/.v -covem --co A y 4:'s45'.0i jvcAtere -Z CONCRETE 0000 Alt" *414 co V'iT'llr CLEAN -FAAIO 4ffACAe)=141 m 4"CAST OF IRON =P/pz /000 )Wj A,.jpjrcwGAG DIS7.' Ne • A 5 H',J=.0 5 M 5jffP7 IC rA)V/< W # I 4E�-nEcrIve ap r'cr ," & 0 4 0, 0 ' a WA5,q,-EP .570NE 4-4 • 000 1 j p -& 0 0 PRECAST 5ZASOPA,4;'&7� P17 OR AMVIV�� 7- P/Am. ,,f,;R7- A7- ff4�1,LDIIV& p r 6 FT c('�E -4AIK 96,y Fr 0 -7- 7 S4CRrIC 7, dl 7- S-=jP7/C 7-A NH 96 .3 pr Box GROUND W,47'ER 7A4&-E -rloN 0A,ITIEC MRIA&-rloly B SeAVA G&E 04SAP4MAL SK571,6M TA 4� IM4E7- BEACHING C;'l 7- zr 7 041LATIDIV LEACH11VCw .4c:'/T '3 Ar 77. SCALE DlMENS10A/ A DArsl6A' CN17�EMIA 6 -7 NlJMBER OF BEDROOMS 3 0, GARBAGE DISPOSAL.UNIT SOIL LOC7 , —10*V 3 3 c� 7Z. r ',,-. 707'A.1- F-'rr1MA"r--jD GAL.IPAY S011- TEST Soll- 7-15's-r*2 JZ NUMAEAP 0.,= 4LOACHINCr .9>/7Z Er4.-v 9 7 p GATE OF 50Ji- 7-R-5r- S1D4E-4,--ACAilMCP JC214FAt A71r P7 � 'I . RESULTS AVIrN&SSRD� BY l6el"I"l</-s 400r7'0/W LAACNIAICr PER Plr-2—&* Sq. &r ^-^I I-L-*COLA7/0" ro'r-4L 4M4CH1.,VCr AREA 2-J6�6 Fgp. cr. =A 2-6,6 Sgp. 7- .7 Arwl-o R- 0 It% F A,4s 4-P7 ROBERT W, bof-A-1 s* C- P. Cc 33 IBUNIKIS No.22162 0 co oo 4 '4 9 411 #j;W 111-7 S q; W71- Zl 7 1 1