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Home My WebLink About0244 PATRIOT WAY - Health 244 PATRIOTS WAY, CENTERVILLE A=193-208 r M .J No. 42101/3 ORA ESSELTE O O O O Jil- ` C J � rb � M Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centerville ✓ MA 02632 April 5, 2017 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: _ > , key to move your r, cursor-do not David D. Coughanowr use the return Name of Inspector key. Eco-Tech Rapid Response Company Name 155 George Ryder Road South Company Address Chatham MA 02633-1621 Cityrrown State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 Furth- �c� he Local Approving Authority ®° DAVID yes o C OW S April 5, 2017 nsp tor's Sign re 114 U. I V U 1j Date The system ins tcp;/ T o a copy of this inspection report to the Approving Authority (Board of Health or DEP) s of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Lapa rS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5, 2017 required for every p page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available." ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 f� TOWN OF BARNSTABLE r*LOCATION / rr� �i SEWAGE # ILLAGE ��r11re� l�c�G C ASSESSOR'S M"& LO NSTALI.ER'S NAME&PHONE NO. EMC TANK CAPACITY /Ozro ,EACUNIG FACIL Y: (type) or (size) rd.OF BEDR:OOMS__._ ....._. .. . ilt"ILDER OR OWNER. ERMIT®ATE: SOMPLIANCE DATE: reparation Distance Between the: laximum Adjusted Groundwater Table to Elio,Bottom of Leaching Facility ect Tivate Water Supply Wdl and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 'Age of Wetland Luid Lcaclung Facility(if any well nds exist within 3IXO fee •leaching facility) IZ Ecet 'urnished by v $� A . -O 3 6-0- 13' r� 1TOWN OF BARNSTABL.E LOCATION C. �G/s',D f W rl SEWAGE # VILLAGE vIfP�Ua I ASSESSOR'S MAP& LOT__ - INSTALIXR'S NAME&PHONE NO. sEPIIC TANKCAPACM LEACHNG F A.CI[H.rff ( �) �� S (size) NO.OF'BEDROOMS BUILDER OR OWNER PERMI'TDATf:..,.._...,w... • C.O.lvLPl.1AXC.E DATE:�..� �.�.�..._�,._. Separation Distance Betweeta the: F Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (if any wells exist on site or Within 2.W feet of leaching facility) Edge of Wetland and Leaching Facility(if any wetlands exist within 00 feet Of leaebin faaciuty) �� ( U Furnishedby. e � S�d..K /"�� a � n 0 v l �UeW er A -o-- 35, C/ TOWN Or BARNSTA.BLE ?CATION / A Vf 71 A SEWAGE # '14LLAGE CenTrv,��t ASSESSOR'S MAP & LOT «3 a09 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IO D � n LEACHIRG, FACIL=: (type) I 1TJ _,size) /M NO.OF BEDROOMS lsl� AND BUELDER OR OWNER G PERMIT DATE: 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 leac ng facility _ Feet Furnished by T/1 SpGv nip J For A a a I 2 3 i I aq`' ia. y. SL f � 3 �eww I SToAj— y P� �rw�aA� i I f TOWN OF BARNSTABLE LOCATION ' P��`� SEWAGE # `.TILLAGE ASSES OR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) e) NO. OF BEDROOMSih BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: t� Zti`GU 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 � b AA ►3 Ab ►a Ac ►-1 AC 31 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5 2017 required for every p 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, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centerville MA 02632 April 5, 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS'is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure'criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters 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 '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5 2017 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection ` Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centerville MA 02632 April 5, 2017 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_4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 gpd t5ins.doc-rev.6/16 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 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centervillep MA 02632 April 5, 2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: According to the original design plan of 1979, the system has a leaching capacity of 549 gallons per day which exceeds the 440 gallons per day required for four bedrooms. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? - ❑ Yes ® No Water meter readings, if available last 2 ears usage d 279 gpd 9 ( Y 9 (gpd)): Detail: 2015: 75,000 gallons 2016:129,000 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.doc-rev.6/16 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 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 April 5 2017 required for every p 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: owner Was system pumped as part of the inspection? El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5 2017 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 37+ years. Original system was installed in 1979. Certificate of Compliance for additional leach pit was issued 10/5/1995 (Permit#95-1743 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' x 5' x 6'-1000 gallon Sludge depth: 4 inches t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5 2017 required for every p 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 Winches Scum thickness 1 inches Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? As built card Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal fiberglasspolyethylene other(explain): ❑ ❑ ❑ 9 ❑ ❑ Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 April 5 2017 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 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 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centerville MA 02632 April 5, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5 2017 required for every p page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to contain 24 inches of effluent Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 Aril 5, 2017 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owners Name information is Centerville MA 02632 Aril 5, 2017 required for every P 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 LL,Oo CA §O nNI SS —OF SEPTIC .COMPONENTS —DISTANCES IN DECIMAL FEET A B _ �ECO-TE lI � 9UTIC SEPTIC 1 29.5 12 2 35 13 3 37 17 4 44 27 5 26 31 THIS SKETCH IS BEST VIEWED IN COLOR FORMAT O� 2 LEACH EX§S T§N CJ 4 PIT D WELD-.UNNG 0-1000 GALLON 0 244 1 SEPTIC TANK LEACH ppp�pn A PIT V Q UJ a LU NOT c CE TO LU o Q SCALE 3 0 w Q PA ` R§Oo lC WA Y t5ins.doc-rev.6/16 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 �1M , 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is required for every Centerville MA 02632 April 5, 2017 page. Cityfrown 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: 25+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/11/1979 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: Town of Barnstable GIS maps You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 2 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS maps indicate that the property is over 25 feet above nearby surface waters. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M y 244 Patriot Way Assessor's Map: 193 Parcel: 208 Property Address Karl S. Purdy and Shelly D. Klein Owner Owner's Name information is Centerville MA 02632 April 5 2017 required for every p 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE IIII I 111 11 111 111 11 �l `P F PRECAST LEACH PIT y to N BOTTOM OF LEACHING PIT LEACHING IS ABOVE HIGH GROUNDWATEA GROUNDWATER ELEVATION PER GIS MAPS t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 —row Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information �- (��I ✓� 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 F rther Ev luation by the Local Approving Authority 1-18-11 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 /I t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Dis o al System•Page 1 of 17 I � y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "non or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further.Evaluation is Required by the.Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is'failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 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 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303i 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 Well 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-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Not used 2yrs 9 ( Y 9 (gP ))� Detail: House has been empty last 2yrs. Sump pump? ❑ Yes ® No Last date of occupancy: 12-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding•tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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: 1995 leach pit was added Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 16" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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 16" Scum thickness 8 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 6 How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Recommend pumping for solids. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from leach pits. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 6 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 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology.- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits in good condition with stain line in new pit at 24"from bottom of pit. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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 0 Lit i F r. U e i — C,r CL y -7 t5ins-11/10 Tme 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 ,M 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 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: 25 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: Original design plans show no groundwater at 12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 TiUe 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 244 Patriot Way Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 1-18-11 page City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E9/111pr,spection Summary: A, B, C, D, or E checked nspection 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 9 P Y P9 P t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 -TO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 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. A. General Information 1. Inspector: 2) 5� v Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-30-09 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. L/�-2-10 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document-03/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 - - 1 b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 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. t5lnsp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 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 S on the site has rp System (SAS)) 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 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 for example: 110 440 ( p gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 12-08 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: Last date of occupancy/use: Date Other(describe): t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 24' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 20" Distance from top of sludge to bottom of outlet tee or baffle 12 Scum thickness 12 Distance from top of scum to top of outlet tee or baffle 4' Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions determined? Tape t5insp official document-OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 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.): Tank is in good condition with baffles installed. Recommend pumping to remove solids. 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.): 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 2-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Water stain in newer pit is at 24"off bottom with no sign of back up. t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for CenteNille MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. - Ne�Ff �.`+ _d- :7 _� . A-L -37' d- - l y' 07' A-G- a6' t5insp official document--03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 v Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Patriot Way Property Address Old Republic Default Management Services Owner Owner's Name information is required for Centerville MA 02632 1-30-09 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: 25' 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 9 you established the high round water elevation: Y 9 Town maps show groundwater at 25'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Slgnatur item 4 if Restricted belivery is desired. ❑Agent ■ Print your name and address on the reverse i to V ❑Addressee so that we can return the card to you. B. Recely by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, A, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No C- 5 �� 3. Service Type t rno1 o2 0-1 Z 0 Certified Mail ❑Express Mail ❑Registered 13 Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (rmnsb. se �i 7006 0810 0000 1525 �878 fromPS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE Mai "3 '�.. 2.Neta e �:a: � �1,,�'•��.. pal p y 11I .K-rly��+,K..-. 1i1<.Y�+, "'M •'� :clv.,�tNt`�."'4i T vF''. ,1177 • Sender: Please print your name, address,and Z10*44619is box a � /��a Town of Barnstable Q') I: Health Division \� 200 Main Street Hyannis,MA 0260, CJ J p. i6a?+ 4{St Town of Barnstable Regulatory Services Department BARNSrABLE, • Public Health Division 9 MASS. Q3 1639. 200 Main Street, Hyannis MA 02601 ArE0 MAC A Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO October 16, 2007 Edward Mattingly 1709 West Street Stoughton, MA 02072 As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 244 Patriot Way, Centerville. Enclosed is an application and a copy of the ordinance. Please use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.bamstable.ma.us. Go to the Health Division page by looking in the Department Menu. There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2008 fees included. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. Sincerely, �v IOU V -Caitie Barrett Health Division Assistant V -Thomas McKean v0 4 Health Director CERTIFIED MAIL#7006 0810 0000 3525 0878 ® -a 0 I i t e r � 1 ° toy . File, Emit Toois i LA - t t - $ : ,.:Pierequisite on Dapt i�ieeiied - apavcd ,' .. Status inspsrrimerd rrrmerat " Status, -. TAX APPROVAL 6300 2e07 LBAR ?,PPR �c� isitxry � d b a A f LTH-HELTFDEPARtE�T Pea t� d a 3._ 47 isn type A'Pf}l1Oti1r'Lnsp�ctvr )rl 'ES 1ESMAR }S:LOIriALI _ _ a ble -<.9500-HEAT#i DEPARTM oGtiontype r f rence: 9517d3 Stags PPFt. APPRtJV - ppl v. . Y u dare _ } rrzrnant ct de 4B _ roved #7 2?�r2 #}7 1 orl�flovR ep ro�rerJ M .- PROP,LlfAJTtb TO 4'BEDROo ]S:MAX # � E _ Test GVRI I SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. S' nat item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse .❑Addressee so that we can return the card to you. B. Re ived by Printed me) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. �� D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Mr&Mrs Walter Taylor I 153 Long Pond Road Marstons Mills, MA 02648 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 1 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) 7 0 0 3 1680 0004 5458 2 7 7 3 I PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 -- I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.C-10 • Sender: Please print your name, address, and ZIP+4 in this box• I PUBLIC HEALTH DIVISION . TOWN OF BARNSTABLE I 200 MAIN STREET HYANNIS, MASSACHUSETTS. 02601 I � I I I I I I I I I I I I Postal ,,CERTIFIED MAIL,. RECEIPT )omestic Mail Only;No insurance .• P rovided) deliveryjor Ln o I F us U $ Postage $ p Certified Fee o C3 Return He Reciept Fee , P M (Endorsement Required) C He wJ Restricted Delivery Fee 2� cDD (Endorsement Required) Total Postage&Fees . y m O Sent Sheet Apt.No.; / `1. .. or PO Box No.1 h CA L o city;slate,-ziR+a �S Form :00 June 2002 I Certified Mail Provides: (as�anaal ZOOZ�un�'00 ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Maii®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Cdtified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. GFZHE A Town of Barnstable * BARNsTABM * Regulatory Services MASS. 9�Ar1 39. A`� Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Ms &Mrs Walter Taylor 153 Long Pond Road Marstons Mills,MA 02648 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 244 Patriot Way, Centerville,MA was inspected on June loth, 2005 by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Conditionally Passed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Septic Tank, distribution box and leach pit are H-10 loading and are located under a stone driveway. The components need to be heavy duty (H-20) loading or the driveway must be relocated. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT COMPLETE • ■ Complete items 1,2,and 3.Also complete A. item 4 if Restricted Delivery is desired. ❑Agent ` ■ Print your name and address on the reverse X1.1 ❑Addressee so that we can return the card to you. B. R ei d by(Prin Name) Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. it '�j✓ D. Is deliv addres different from item 1? d Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Ms Daphne Clark 244 Patriot Way Centerville, MA 02632 3. Service Type ❑Certified Mail ❑Express Mail ❑ Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2.,Article Number 7M3 1680 . 0004 5458 2759 - (Transfer from service labeo LForm 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVIC!P—,---,, .,first-Class&W- P&stage-&'Fees Paid USPS Permit No.G-10 • Sender: Please print your qqAe, address, and ZIP+4 in this box • PUBLIC HEALTH DIN'JISION i TOWN OF BARNSTAMLE 200 MAIN STREET HY"NIS, MASSAC-RUSETTS. 02601 70Ln CERTIFIED :MAILTm RECEIPT (DomesticOnly; Provided) U.S. Postal Service-r. fU For delivery information visit our website at 0 CO Lr) Postage OCertified Fee ReturnReciept Fee o Pyre`I` tr}1 (Endorsement Required) / N p, Cqi � Restricted Delivery Fee �� —_j J/ cO (Endorsement Required) Total Postage&Fees m O Sent To 121s:-�Aege .. K N Street Apt.N. VV�cx r or PO Box No. r, C -S ------; - ----------------------- --- ---- �¢-...........----- �e�ter✓'c.� � yyl/-� o� 3/�, Certified Mail Provides: (asranay)ZOOZeunf'ooee'++ao�Sd ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. CFTHE F, . Town of Barnstable 9BARNSTABLE, Regulatory Services 1639. Thomas F. Geiler,Director ArFD MA'S A � Public Health Division Thomas McKean,Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 19, 2005 Ms Daphne Clark 244 Patriot Way Centerville, MA 02632 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 244 Patriot Way, Centerville,MA was inspected on June 10t', 2005 by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has"Conditionally Passed"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Septic Tank, distribution box and leach pit are H-10 loading and are located under a stone driveway. The components need to be heavy duty(H-20) loading or the driveway must be relocated. You have two years from the date of the system inspection to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Pd CQ l r"T s COMMONWEALTH OF MASSACHUSETTS ® e,7s/2 - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ?Jn DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _244 Patriot Way Centerville MA 02632 Owner's Name: _ Danline Clark Owner's Address: Date of Inspection: June 23. 2005 Name of Inspector: (Please Print) Jantes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 c� Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT Z 0 .Z; I certify that I have personally inspected the sewage disposal system at this address and that the in ormation-re orted below is true,accurate and complete as of the time of the inspection. The inspection was perform d based�bh my it; training and experience in the proper function and maintenance of on site sewage disposal system . I am ra.DEPM approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes ✓ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 29, 2005 The system inspector shall submit 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. Notes and Comments ****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. Title 5 Ins pection ection Form p o m 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 244 Patriot Wav Centerville MA Owner: _Daphne Clark Date of Inspection: June 23 2005 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: 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 ND explain: obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 C. Further Evaluation is Required by the Board of Health: ✓ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: The septic tank,D-box and leach nit were H-10 loading and under a stone driveway Needs to made H 20 loading 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 . o OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A new pit was installed on 1015195-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 2' Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to he an signs of leakage NOTE The outlet side of the tank is under a stone driveway, Recommend makin it H 20 loading or moving the driveway. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Patriot Way Centerville MA Owner: Daphne Clark Date of Inspection: June 23 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. NOTE: The D-box was under a stone drive w . Recommend makin it H-20 loadinLyor inoving the driveway. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Conunents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 244 Patriot Way Centerville, MA Owner: Daphne Clark Date of Inspection: June 23, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: 1 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.): The newer nit had P ofliguid on the bottom. The sides were clean There did not appear to be any si ns of failure The cover was 12"below,erade. The original pit was not dug up It was under a stone driveway Recommend making it H 20 or not driving over the leach nit. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 D OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Patriot Way Centerville,MA Owner: Daphne Clark Date of Inspection: June 23, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. R 1 i a � i � Q 1 3 1 39� la y a 3s ►3 � , o � naww P SToAL S a� 3 ► , 10 y Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 244 Patriot Hav Centerville MA Owner: _Daphne Clark Date of Inspection: June 23 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:_ Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_ tODOYYa17hic and water contours mans Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Usinz Barnstable to o ra hic and water contours ma s the ma s were showin a roxitnatel site. 25'+/-to round water at this This report has been prepared and the system inspected and found to be in need of further evaluation as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION �G. SEWAGE # VILLAGE Cam- y � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �l� �� — (size)' r'f :51� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PJ BUILDER OR OWNERCl�✓ — DATE PERMIT ISSUED: 9�� S DATE COMPLIANCE ISSUED: 4 Lci -- 9z VARIANCE GRANTED: Yes No (3o</7 a Fc- � A rk Cam, (34ov�� ct ? y r f _ s8Z :L.0.C'A'T IOM SEW A G E PERMIT NO. Y'ILLAGE CEAy T"o,P y Al 14 INSTA LLER'S NAME i ADDRESS W;-/ wel"er B U I L D E R OR OWNER 1041Y S!Occ/V Ay DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1p_,l 7p /T�/4/7' Al®e,'fOC- � w - H k91z - )0K . VHUSETTS No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASS 01pprication for ;Digpo!6al *pgtem Cowaruction Permit Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. ( Installer's Name,Address,and Tel.No. CC _ _I -' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedroom Garbage Grinde Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3_7 c� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil n-e— sc p Nature of Repairs or Alterations(Answer whe applicable) �U Plt+ Date last inspected: D 0lev(5/ Z✓ .7�"�� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been! sued by this Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS k Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(�)on by - �.. for Qsn6c r"Jt C\.r V, ark i q YL N v - ,has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: .. , ^� ---- No..�-- Fee --�_—� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5pogar *p!5tem Cou!5truction Permit Permission is hereby granted to to construct( )repair('*�an On-site Sewage System located at 2 C_j Lf f k—ci C Ilc rc"4,4, r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construct io mus b completed within two years of the date below: Date_: Approved by 7 VH No. THE COMMONWEALTH OF MASSACHUSETTSPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSS Zfpplir tton for Mi!5poal *p5tem Construction 3pCrmit ,w 1 Application is herebyrmade for a Permit to Construct( )or Repaif"( an On-site Sewage Disposal System at: i Location Address or Lot No. —~ ,Owner's Name,Address and Tel.No. \ oqc( \�kCl�d�S Gx� C� r'v� `�Q �VOU C\ c.. e-t,-�-exVi1� Installer's Name,Address,and Tel.No. —r Designer's Name,Address and Tel.No. t � � Type of Building: r Dwelling No.of Bedroo ` Garbage Grindko Other Type of Buildina No.of Persons Showers( ) Cafeteria( ) Other Fixtures / I Design Flow 3 c gallons per day. Calculated daily flow gallons. Plan Date Number of sheets yN , Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) 44NU C k, P 1t+ --J A A RA Date last inspected: OYO,'`—/61"'N -77'� Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of-..Compliance has been issued by this :`r J +' Signed 0 Date I r a Application Approved by a Application Disapproved for the following reasons �� Permit No. "' Date Issued A4 No.�`7�l' �'�- -3D J~ ;� Fzcs.............................. THE COMMONWEALTH OF MASSACHUSETTS BaAR® OF-HEALTH S6wre.............OF.........Barnstable Appliration for Bi-opwi al Works Tonstrurtion ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at Patriots Way, Centerville Lot 23 ................-....................... ....................................................... ---- ---------------------------•------........ cation-Address or Lot No. .1 .1. :.4..... cc.----.��.................•-•-----.-. -......b',.J`�.t4.�.[!9 y- Own Address � Installer Address U Type of Building Size Lot--------18_,.95.5---Sq. feet Dwelling—No. of Bedrooms.._......,3...............................Expansion Attic ( ) Garbage Grinder PO) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow................5..5__.....................gallons per person per day. Total daily flow------------------33.Q_.................Olons. YJ GG Septic Tank—Liquid capacity..1.00fkallons Length.... Width...,+.__a.Q_ Diameter................ Depth...5_..._ .... W Disposal Trench—No. .................... Width....__.._....___._.. Total Length.................... Total leaching area....................sq. ft. x . Seepage Pit No--------I........... Diameter....1O t........ Depth below inlet.....6.1.......... Total leaching area.....OF...sq. ft. Z Other Distribution box ( X) Dosing tank ( ) aPercolation Test Results Performed byCape---Cad..5urv4-V._.C.Q.MLiltlntSDate..........7110/79.......... ,a Test Pit No. 1.2............minutesperinch Depth of Test Pit. 2............. Depth to ground water_.A9Ae.......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate • a -••.................................••-••-•-•••••-•••••••••.....•-•-••........................••......-•-•---•-••-•.----- ,�Fp4�N �F Mg�S9 0 Description of Soil....O..Q--Q.._5...WOOd...Z0.3A)}...Q._5.- .�5....rSl b_ ��1_..___2_jt_r1-_n12.O_•- tS '--RENVi..CK c��, ---••---sand.----••••• ---------------•-•-•-••-----••---•-•----••......---- ----------•---•••.......................- Z.......----8.••-•••--•- ----•....... ......•••• CDG4-FARAE}lkPl a� V Nature of Repairs or Alterations—Answer when applicable------------ ___ __________ ___ . . . ............. Q-.. Agreement: (17/27 ONAL The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc with the provisions of iITL is 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ed.... '". " Date Application Approved By......... . ��•s j� G( �1V_�_.......................... ....9.-YY--.91:..---•-----•- Date Application Disapproved for the following reasons------------------------------------------------------------------------=---.................................... ---•-•••-•-•••••-••••-••-•-••-•••-•--••....................•••••••••••••••--•-••••••••-•---•----••-••-_....•-•••-••••---•••---••-•••--••-•••-----•••---•-•••--•-••-•-••--•-----••••-•-------•---•--...... Date Permit-No:-:.....:..- .... - --••----------__•-----•--•----._.. -- --• Issued....---•--••-------��. -�{-`--------•-------- Date t 4 �� f tFEic Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF—HEALTH ............. dwn� of ..:: Barnstable ......... ... Allp iration for Diipoiia1 Workii Tonitrnrtion ami# Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: .........Patriot,s Way,---Centery lle Lot 23 -........ ----------------------- --- ---------------------------------------..........,--------- Location-Address or Lot No. Owner Address W V Installer Address UType of Building Size Lot........1$Vt55...Sq. feet ,., Dwelling—No. of Bedrooms---------- ................................Expansion Attic ( ) Garbage Grinder fiC) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) PaOther fixtures ....................................................... Design Flow...............5 ........._............._gallons per person per day. Total daily flow.................310..................gallons. P: Septic Tank—Liquid capacity.100%allons Length A.W!6t'.. Width__J+!jW1 Diameter_______________ Depth.. !.1+�i._. Disposal Trench—No. .................... Width.................... Total Length._........_......_.. Total leaching area.__.._......_.......sq. ft. 0. Seepage Pit No_______I___________ Diameter..],Q!._ :_._. Depth below inlet....! {.......... Total leaching area.....29jr...sq. ft. z Other Distribution box (X) tDosinijank ( ) Percolation Test Results Performed bf-#j ...Cod..SICI vey-----Gt>31:3LtltantS Date.........7/10/,79........... aTest Pit No. 12.............minutes per inch Depth of Test Pit12.1............ Depth to ground water_mozie........... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..... p4 ................"---.....-------........... ... ....•------------•-••....---•-•••-----••--•-••••••.....••••........... ASH iif O Description of Soil...Q.0,44-5_-wood-wood -aut .4m2.. $Libaoli.t...2,-5-.l2-.Q..-Med `.'P .......... ?jP , W ,Santi.........................A'`'� }. -------- •---.------ -.- � ...-REN�nIJGI< yN ---------------------------- -------------- -------------- --------------•--•----•---•----t--- .................... -- r" �.. 0 —1 } U Nature of Repairs or Alterations Answer when applicable ... _ --------------- ..... ............... y ......................................... ...... ............................... - -` g •...._....._........... A Agreement: r 1 .. 7/7/.. ��s�/STE�G F The undersigned agrees to install thex�afd'redescribed Individual Sewage Disposal System in acc 0 t EN the provisions of TITI.^. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been"issued by the board of health. r� �'" Sig d .............................................•------.................-- •-••----------------•.--•------- J�+r - # , M ate Application Approved BY----•---- r• ---, .. . .1�1 _. ...-•...................•-- -._�..---�--"--�-��--'-•........... � �� Date Application Disapproved for the following r'as_ons---------------•-•-- .. I 1 Date Issued.-•--4-----------=....... Date THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH 11rr' firatr of To lianrr TH S I TO CERT F at thejIndividual Sewage Disposal System constructed ( or Repaired ( ) by.••--• * . .. ,..._... . ----- --------------------------------------------• -- - -------•--•- . � Installer y=-- -_% - � has-been installed in accordance with the provisions of TI, 5 of The State �3anitary Code as described in the application for Disposal Wo°rks Construction.Permit No-- _.___ --__. `_ a--__--.__- dated-.... __+:. '.. .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................•--•-•-......----•-----------•------•-•....-••••---•-----•_..... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N . �` .. Z ........ ...........OF.... ... l 1.. ...........:... FEE---. ""�"` . Dispogat Ar B n u ion panfit 'Permission is hereby granted .----- --_ ---' --------------------------------------------- ............. to Constr c . ( �ij'or ep P4.4-_ ) an Individ . 1 S gage DisposMSym�r+� `- � Street as shown on the application for Disposal Works Construction PergW No.._ *Bo Dated........ ............. 1/�'/Q ��r of Health • DATE..... (/ ..`-.-- ............................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 3 Tm �, y ref.!)I-,,- 6L/ L� &W q4-1 0Wh r t�✓w, Cd ` �s�'i�tu,,p o[�lew�, 7 / SO r` - (�6P1✓I f 9 0 over0A -lift �p y 4 11 d4 lf�, clim 4,4"d#0 �V/� 1 f f Wa y as Et�A 1� 3 Q� Z C'.f; r TOWN OF BARNSTABLE r ,7012 OCT -- i Fif 11: 3 I - DIV . ..... -z"' 'F'';°€`;'?i.x`, "" °' "?tY,,'„ ^p"4'°»- -... .. .-;.l'-,''+""'q'" - yE'� ,`�•_r •�4 'T'.>' - ,..`a ?'A"'"'- -'si/'--. -s§'x^i. Yt s 4- ,,.t -.r.,.. 4;r,. 77 po - Zu� P � — . I i 3 f _. ,.. •- ..3f'b+f aaa ^F, s�mrw.. 'a&., a:�sa= _s�:f,r ,e.a. ?r. /✓ � k .�: a�A" .� �/ _ .� �' _ �� ZLI� PgkiDI / � IS t Q N Cs- Um t ._ a., >�..r -a ,.. .... . _._.�.w.,... .• - _ n� yam`. .4..-.�...-+...--.m•. ..' �.-+.--••---,-,..—,.- _..�s� _ .. ...ter - �, '._ __ — 1 ® f i G C� .. t r I MCK UWT�u I lei % w LITY tED RM El -- t go /010" W-WWQ� I-V r._ f�y . LLV LL � 4u PATRIff WAY oEuc F7 VIDE I � I LOWFJL 11 EVE) IJTILaY RM RK ago — caw 2 CflR --_ . UWE _ uai __ r r SOIL LOG Sl y Y! PEASTONE .LOAM 9 FILL MAX ✓pU� � �) / o —oo - `,•Y.� • Oar/ ��Q A 4 C. I. nOX e7_0 1000 I;.o�o 0 1000 GAL. ° e o • 1 �o 10 MIN. GAL. �'e °e PRECAST OR o I" 24" SEPTIC I•;• • '. ° . ° • I . M,IN TaC3T� BLOCK p TANK 6� 1`,;�'•`. > ,y i I, °e SEEPAGE S( I esvd8, PIT - 1 e;0 e•17 5 20 MIN. •FOUNDATION I %2" WASHED STONE-' I I ELEVATION SKETCH I 10' PERC. RATE SCALE I = 4 TEST BY TOWN INSPECTOR BACKHOE OPERATOR: r TEST MADE ON : _ At t ool -89 �. P£'Go'G+S1 I.i ¢�' x' }• haoC�tB p 3 BLFple0-1ri4 l o'm A � 5e,077C -T; Fors 7 a BOX~ 9 G••,£7/7E t?/y_; t�c.�1 a c+.oc �-7 _ 3 BloRoumZ (sue (aQeSAQC,E are rHa4ERjr rrvG.ac�a�r'/�• ?.3'0 Hsu/.a�afl lot x_ �� 2J/1h7.4! AGGocvs,'�C'�s t��ict- FLG1�' ;�v,�; %TNF5 SYSTEr� V .Rd-rro'-2 s 29 S 2<7 S. 5-4 w,) 743wef r 47"L-,e ' LEIiENQ a -=v Cam ' ELEVATION 71 SCHEDULE • PROPOSED SITE PLAN I. INV. AT FOUNDATION _ 5'G 39 2. INV. INTO SEPTIC TANK = 1,76 29 SEWAGE SYSTEM PE,,SIGN IN 3. 1 NV. OUT OF SEPTIC TANK 9G.o4 n 4. INV. INTO DISTRIBUTION BOX, - 9S 77 SCALE : I°= 2pf ,:�U 1979 5. INV. OUT. OF DISTRIBUTION BOX = `I5, C - ✓„�7-f 6. INV. INTO SEEPAGE PIT _ 15.50 CAPE COD SURVEY CONSULTANTS 47. BOTTOM OF PIT = 7• `'0 ROUTE 132 HYANNIS ,MASS. . ti