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Home My WebLink About0003 PINE TREE DRIVE - Health 3 PINE TREE DRIVE Centerville A = 208 - 027 - 002 1 No. 42101/3 ®RA i ESSELTE 10% O 0 0 0 r I' Commonwealth of Massachusetts o2 08-ba "-7--COL. ,R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., 3 Pine Tree Dr I`r Property Address Louise Hill Owner Owner's Name information is Centerville required for every MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. " Important:When filling out forms A. Inspector Information on the computer, use only the tab Darrell Stone key to move your Name of Inspector cursor-do not Cape Cod Septic Inspection use the return Company Name key. P.O. Box 1466 rrb Company Address Harwich Ma 02645 City/Town State Zip Code ztu� (508) 240-2500 S14995 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally asses 3. ❑ Needs F rthe Evaluation by t Local Approving Aut 4. ❑ Fails 5-19-2020 Inspect r' Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 t , Commonwealth of Massachusetts Title 5 Official Inspection Form in Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Dr u- Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State .Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5lnsa.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is Centerville required for every MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): •t r 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �R ,p Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments « � 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other. 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5in5p.00c•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal Form - Not for Voluntary w Di l S Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is Centerville required wired for every MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310,CMR 1.5.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be -necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 t5in5p.doc.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �ro Title 5 Official Inspection Form 1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® a ❑ 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)) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts : F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments / 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): NSA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: 2 bedroom residential dwelling N 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 84.9 gpd 9 ( y 9 (gpd)): Detail 2019 -33,000 gal 2018-29,000 gal Sump pump? ❑ Yes ® No Last date of occupancy: curentDate '5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Unknown Wass stem pumped as art of the inspection?y p p p ❑ Yes No If es volume pumped: y gallons How was quantity pumped determined? Reason for pumping: =5inso.doc•rev.7/26%2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary 9 P Y o tary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name required for is every Centerville required for eve MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 25"+/- 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.): Apparent good condition t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16 , Commonwealth of Massachusetts I ,1P Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection Do System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1911 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 gallon H-20 - Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 4 1 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 1.5 years Recommended maintenance pumping every 2-3 years 5insD.00c•rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 1a Commonwealth of Massachusetts ,@ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3 Pine Tree Dr u Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ,❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments «1 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) a 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ' ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Did not locate due to location and digging conditions. Water flowed from the septic tank into leach pit with no indications of a problem. :5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is Centerville required for every MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1, H-20 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1, H-20 (4x6') pit with stone Grade to pit 36" Cover 19" Bottom 87" Ponding 13" Staining @ 6" higher No sign of hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure,`level of ponding, condition of vegetation, etc.): :Sinsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Fora (� Di S rf Subsuace Sewage Disposal System Form - Not for Voluntary¢� ry Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name required for is every Centerville required for eve MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts n Title 5 Official Inspection Form 7� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A b I A { 3 C Ali- 2 4 I 1- I E t5inso.doc-rev.712612018 Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 16 of 15 Commonwealth of Massachusetts. Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name information is required for every Centerville MA 02632 5-18-2020 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 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: 1986 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: See below You must describe how you established the high ground water elevation: USGS maps are approximate Property ELV. 41.0 Bottom of SAS ELV. 33.75 GW ELV. 16.0 Separation > 4' i i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7t26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary�� Sb Assessments 3 Pine Tree Dr Property Address Louise Hill Owner Owner's Name, information is Centerville required for every MA 02632 5-18-2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ti No. '�1 /J� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS off.3�y Application for Misposal *pstem (construction permit Application for a Permit to Construct( ) Repair(6 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 P<<^c TiB` D JA Owner's Name,Address,and Tel.No. Assessor's Map/Parcel '02 63v2�t Installer's Name, Address,and Tel.No. , eA0 Ad Designer's Name,Address,and Tel.No. LIA- QQ __ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �J Design Flow(min.required) gpd Design flow provided 33 o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Rey, )fc)�Vle,,e << Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to lace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date (I—,X 5 t cl Application Disapproved by Date for the following reasons r Permit No. go Date Issued No. I L /3 Fee / " THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9 application for-Disposal *pstpm Construction Permit Application for a Permit to Construct( ) Repair(o6 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 Pi=^e 'j ie e- Da Owner's Name,Address,and Tel.No. Map/Parcel C en �v-`�r< Assessor's Ma ,A- P 62 6s'2 1• �. � W�' ��' G��Q yG/�ra� f� /� Installer's Name,Address,and Tel.No. �,°��o n D Se`f' Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33d gpd Design flow provided 33 o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �;j'} I; 6 to its Q Re OS-C Ce, ✓tied►� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. � ' Signed Date Application Approved by Date f 1-1 5 -f Application Disapproved by Date for the following reasons e � Permit No. o�C) y 53 f Date Issued ----------,------- -------------------------------------------------------------------------------------------------------------------- 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS f Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by Z)i 4c a V7�0 S e_r,✓ -y ca-,/ OR e_,', at -3 D e -e2 66 h-F a✓'lias�een constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..201,q-t-+53 dated f Installer Designer f #bedrooms Approved design flow" ,—\ ,�{ /`,q gpd A G Yj The issuance of this permit shall/notbe donstrubd as a guarantee that the system will fun t on.asj)d"si/ned f'' i' ;'�f �� i Date / � Inspector , /_16,1 ," "J �,?i --------------------------------------------------------------------------------------------------------------------------------------- No. a of LI— y 3 - A) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(tx) Upgrade( ) Abandon( ) System located at 3 !p 1-✓r-C 4-1 e t V e-. eel f /(�,��{ �/yJ (>7( � and as described in the above Application for Disposal System Construction Permit. 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Important- When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key , r to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector ._ key. D.A. BROWN Company Name 0 tad P.O. BOX 145 w Company Address ACENTERVILLE MA co rn 'e""" City/Town State 2632 ip Code 508 420 4534 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/25/07 l4pec Signature Date The ystem 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. Tide V Inspection Form.doc•08/06 Tide 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 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4125/07 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: 4'X6' LEACH PIT HAS ABOUT 1' OF LIQUID IN IT AT THIS TIME 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 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 tha n 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. Title V Inspection Form.doc•08106 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required re wired for MA 02632 4/25/07 every page. Ci frown 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 '/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. Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection p on Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y� 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Title V Inspection Form.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms 3 2 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 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)): 05-50 06-104 Sump pump? ❑ Yes ® No Last date of occupancy: 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): Title V Inspection Form.doc•0&06 Title 5 Official Insp ection 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 ' 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required re wired for MA 02632 4/25/07 every page. Erty/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 OFF AS BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: • 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.): Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y El 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 GALLON Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Title V Inspection Form.doc•08106 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 '< 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is CENTERVILLE required for MA 02632 4/25/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK LOOKS FINE AT THIS TIME/FAIRLY CLEAN 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): Title V Inspection Form.doc•08108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page to of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name required for is CENTERVILLE required for MA 02632 4/25/07 every page. Cityrrown 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc•08106 _ 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 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required for CENTERVILLE MA 02632 4/25/07 every page. Cityrrown State Zip Code Date of Inspection D..System Information (cunt.) 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: 1-4'X6' ❑ 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.): PIT HAS ABOUT 1 FT OF LIQUID AT THIS TIME STAIN LINE NOT VISIBLE Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 't 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required for CENTERVILLE MA 02632 4/25/07 every page. Cityrrown 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.): Title V Inspection Form.doc•08106 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 '< 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required for CENTERVILLE MA 02632 4/25/07 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. I 16 U Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 PINE TREE DR CENTERVILLE MA Property Address LUNDBERG Owner Owner's Name information is required or CENTERVILLE MA 02632 4/25/07 f 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 ground water: 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: Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �t 5••' RECEIVED JUL 2 7 2004 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES L DEFT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ®� fJIAP Property Address: PARCEL ',0 2ej obZ �.L�.►Via`\1 i Owner's Name: -s#ems�, t-Or -- Owner's Address._(ec Date of Inspection: �/� S/ 0 Name of Inspector:(please print) 61 @ter/ Company Name: i7 L4wd-3 t�iuplsc,�,l fcaST. Mailing Address: ,S y p c 4 moo/ Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function 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: asses _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: y s f0 Lf 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. 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 Inspection Form 6/15/2000 page 1 I� Page 2 of 11 t y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Ri «p Owner: a Date of In ection• Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 r Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 •Qc Owner- Date of In ection• 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 t Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a man er that protects the public health,safety and environment: _ The system has a septic and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tribu 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. Title 5 Inspection Form 6/15/2000 3 A` Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Ins ction: o 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 charge 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 _ -L,�Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow fequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _z,--'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 �°ater supply. / Any portion of a cesspool or privy.is within a Zone 1 of a public well. _ -LzAny portion of a cesspool or privy is within 50 feet of a private water supply well. y 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.] VO (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 convect the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"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 00 feet of surface drinking water supply — — the system is within 2 0 et of a tributary to a surface drinking water supply _ the system is locate m nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a pub ' water pply well If you have answere yes"to any ques ' n in Section E the system is considered a significant threat,or answered "yes"in Section D ove the large system 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 Title 5 Inspection Form 6/15/2000 r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: LT 1—ul .lea Owner: Date of pection:�2� o$/ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Plumping information was provided by the owner,occupant,or Board of Health z/ 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 . cf Have large volumes of water been introduced to the system recently or as part of this inspection :' -lz'— Were as built plans of the system obtained and examined?(If they were not available note as N/A) fWas the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out zZ'— 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)] Title 5 Inspection Form 6/15/2000 5 J Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Ins ection: o FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .Z DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):�® Is laundry on a separate sewage system(yes or no):A[Q [if yes separate inspection required] Laundry system inspected(yes or no):-rA(O Seasonal use: (yes or no): Water meter readings,if.available(last 2 years usage(gpd)): oho o02 ,�to'000 /�®03 S� ° ''� Sump Pump(yes or no): Last date of occupancy: �d e�c a il2o-cv �— COMMERCIALANDUSTRIAL Type of establishment: Design flow(ba d on 310 C 15.203): and Basis of design flo (se rsons/sgft etc.): Grease trap present s or no): Industrial waste of g tank present(yes or no):_ Non-sanitary aste 'scharged to the Title 5 system(yes or no): Water met readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Vole orr Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM eptic 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: Were sewage odors detected when arriving at the site(yes or no):�Q Title 5 Inspection Form 6/15/2000 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 Owner. G Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: a Y Materials of construction:_cast iron 40 PVC kl`pther(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: 1V � Material of construction:_c//oncrete_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: x 9 S 13 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: cf-V Scum thickness: AWte Distance from top of scum to top of outlet tee or baffle:— � Distance from bottom of scum to bottom of outlet tee or baffle:_dltA' How were dimensions determined:T7-/Ji°.¢srs� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leak—age,etc.): _ �C-t3Ll �-+.c..e.Pz�si,:t > T�`�*•�P /�.rG"'w,p �`'``�?"y 3 ��• .. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of to top of outlet tee or baffle: Distance from bott o cum to bottom of outlet tee or baffle: Date of last pum g: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 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: Owner: Date of Inspection: 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: allons Design Flow: allons/day Alarm present(yes or o): Alarm level: Alarm in orking order(yes or no): Date of last pump' g: Comments(con 'lion of alarm and float switches,etc.): DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: ocate on s' a plan) Pumps in working order(yes o): Alarms in working order(ye o no): Comments(note conditio of p p chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: •�� e Owner: Date of In pection: 1- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid t inlet inv Depth of solids layer: Depth of scum layer: Dimensions of cesspool- Materials of constru n: Indication of groun ater inflow(yes or 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 soil, 'gns of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Title 5 Inspection Form 6/15/2000 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: T� Owner: Date of ection• a 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. Title 5 Inspection Form 6/15/2000 10 I r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ili+te Owner: Date of In ection: (p�,� sT V SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water�,,Reet 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: O served site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: � �Checked with local excavators,installers-(attach documentation) _Z_ ccessed USGS database-explain: You must describe how you established the high ground water elevation: y0 . D � � y - ,-T. ;2 �2- 2 Title 5 Inspection Form 6/15/200.0 11 N LOCATION S. SINA. GE PERMIT MQ LOT 41B-PINE TREE DRIVE 86-747 VILLAGE ' ASSESSORS MAP NO; 208 6� CENTERVII:LB; MA PARCfI°NO.: 27 � INST A I�. ER'S NA_ME i ADI) RfSS B:C.K. - 97 TOW11tV BROOK ROAD WEST YARMOUTH, MA 02673 y # u EaE R R OWNER BOND REALTY ,. 13 DATE PERMIT tSSIJED 7/10/86 -DATE COMPLIANCE ISSUED 9/10/86 w 1I/V - Z �� s TOWN OF.�BAARNSTABLE LO'c`TION ) /'�' SEWE`W VILLAGE � � ASSESSORS MAP & L TZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ( (size) NO. OF BEDROOMS__ BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) ((''�� Feet Furnished by �� Owl 76 AAIy C �b 1� RA t9 g 8 is 3i Y L ! CATION SEWAGE PERMIT N0. LOT 41B PINE TREE DRIVE 86-747 V i l l A G E ASSESSORS NEAP NO: 208 CENTERVILLE, MA PARCEL`NO.: ° 27 INSTA LLER'S " NA-ME , & ADDRESS B.C.K. 97 TOWN BROOK ROAD WEST YARMOUTH, MA 02673 B U I L D E R OR OWNER BOND REALTY DATE PERMIT ISSUED 7/10/86 DATE COMPLIANCE ISSUED 9/10/86 9x 019 • F; ,,ASSESSORS MAP NO: 20g -2 7 Fps.. 75�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF......................................-----------------------------------................. App irFatilan for Disposal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at PihTree. Dr y„e-----�{�.......... R------------------------- �...- ........................................................ Location-Add r ss or Lot No. �. eIG .._ 3-E X e 7 .. ..l P..S.. �i...•...f±�.4........... •---•- •--•-- Owne^ t .............................................Address Installer Address UType of Building Size Lot----o 0/57---------Sq. feet ,., Dwelling—No. of Bedrooms...................:...._._......_......Expansion Attic ( ) Garbage Grinder (�* Other—Type of Building _.lg.V.�f............. No, of persons............................ Showers ( ! ) — Cafeteria ( ) a Other fi s .•--.........-••-••••••.......... W Design Flow............................................gallons per person per day. Total daily flow...............//®...................gallons. WSeptic Tank—Liquid capacity.AO.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length............. .... Total Total leaching area........._..........sq. ft. Seepage Pit Now__-__•-.I--.-_-__-- Diameter..........^L-n Depth below inlet._.... ._...__ Total leaching area._.Z_ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1...... inutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .......................•- •-•-•--••••-------•••--•---_......••---•-._............... ...... yyyy�� i O Description of Soil.... '.1_�_••--5� -••`�....... !�'t�` ..------•-• S'T t e U ......................................................................................................................................................................................................... W M ........................•--•-----........•....._....__......__._._..................................__........................._............_...._...._._........._..._.._.........._...._._.__.___..._. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------------------•-•-----•-------------.....••••-----•--•-.......•••-•-•-•••••••••--•••••-•-•••••-•--•-•-....•••--••....----••. -••-•••-•••-•-••-•••••------••----•-. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accorda with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place sy , in in operation until a Certificate of Compliance has b n issued by the board of health. C i 2 / Signed••. .............................. C J n� � Application Approved B ............ `�� 7 Z71 $J. PP PP Y.._.. V tJ Date wi Application Disapproved for the follong reasons-............•...................___------------------- ..--------•-----------•--••-- ----. ---____----_ .........-••-•••-••••-••.............. ..... ....••-•••-•.....--••••••------•-•-.....-•----•----••-•.._._..._.._....-•-••••••••----•••----•-•-•••••--••••-•---...----------.......- ---••---•-•-- Date PermitNo......................................................... Issued-....................................................... Date ------------------------------------------------------------------- 2 D —7i / , Fles............._....._..... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ :........................OF............. Appliratiun for Diunuuttl Works Tontrurtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- - Locati Add ss or Lot No. -- 10. ..s........- _ .�-r!................... 3 ... .4�.=,�.. �. .._--.... .. Owner Address -- !� --=C t..!L).. .............................. ..........................•------......------:...----•-•--•------...('.......�................ Installer Address Type of Building Size Lot...... .......Sq. f aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (N - a Other—Type of Building _./�I.f�v S__ ...... No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fia 5es -----------•-------------------•--------....-•--------.••----••••-------••----------••-•----•--•---.....•-• j W Design Flow............................................gallons per person per day. Total daily flow...................._....._.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—Nq--------------------- Width ........... Total Length.......--. Total leaching area.....';�.463 q. ft. Seepage Pit No:.................... Diameter.................. Depth below inlet........ Total leaching area.................sq..ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results ZPerformed bY.......................................................................... Date........................................ Test Pit No. 1.......�. ..minutes per inch Depth of Test Pit.................... Depth to ground water.................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w' ---------• -- ... - - — ...... ........Cue •e D Description of Soil-••••---•-e� �.-- U �•- r»- / t V .---------------------•....•---...--•--•--------•---..........._...---•--•---•••--•••-•-•--.....-----••....•------••-------••--•••--------•---- ---•---•----------•........----.......--••--------•• W ------•---------------------------------------------------------------------------------------•------------------------------------...-------•-------...---............----------------•-........--••-- M. Nature of Repairs or Alterations—Answer when applicable..........................................................:..:.................................. •-•----...-•---•------....•..........................................•---..............---...........••.....•----•-•----........••. Agreement: The tndersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordan with the provisions of T ITLS 5 of the State Sanitary Code—.The undersigned further agrees not to place tlp sys em in operation until a Certificate of Compliance has been 'ssued by the and of health. w t fi �" Signed........ . 4...--- - < ,u"" ', 2�2 Z7 7 Application Approved By...........-.. . .......... ..........•---.... _ ...................... Date Application Disapproved for the following reasons:--•......................................•----------....--------------.....---------•--•--•-•....-••--....--- .............•--......•---•-..............-----------...---------...---------..................D�..._....._.._ PermitNo...`.....-•-----•-_.....--•----•-•-•--------------_ Issued..................................................... ... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........W.......................O F........3.......... .......................................................... (Irrtifiratr of Tontpliane THIS IS CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at............. I•------�---------- . ......... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s descri))ed in the application for Disposal Works Cons-truction Permit No......... gy_7... dated........ ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA�ANTEE THAT THE SYSTEWILL FUN TION SATISF#CTORY. DATE.... ,.............. = .. ........ Inspector.................................................. ...................---••--- THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD PF, HEAL. No. <d�?.. . 1 .......... ...............................OF.....---- Fn... �......... Disposal Parks Tonutritrtion Permit Permission is hereby granted............ � ..N_... ......................................................................... ....-- to Construct )3or Peft. ( a divi � ge D}�s t U )L.(_c� atNo.................... .....--- Street as shown on the a lication for Disposal Works Construction Permit No..�' >..��7Da d........_ .._-- ...... ............. .......................... Board of Health DATE 'L r �r . ...•.......................', 9 +: FORM 1 ss A. M. S LKIN, INC., BOSTON �� ;$\\ LCATION3 SEWAGE PERMIT N'O. LOT 41 B PINE TREE DRIVE 86-747 V i L L A G E '=S;ESSORS MAP NO: 208 CENTERVILLE, MA PAR ;Ef P'R. 27 INSTALLER'S NAME A ADDRESS B.C.K. 97 TQZN BROOK ROAD WEST YARMOUTH, MA 02673 S U I L D E R OR OWNER BOND REALTY DATE PERMIT ISSUED 7/10/86 DAT E COMPLIANCE ISSUED 9/10/86 t v lco" DESIGN DATA �x l ST.I NCs �<1 STRUCTURE SI Is_j L_EE7 f=&KA 1 L_Y DWEl-L-• DESIGN FLOW��RM/N c, G. G ,�X I IO c�P•nl '�nRt� = 3� 411, E a SEPTIC TANK USE Iocn 7 c��>A.C-.1 H-ZO SLA- I _ `` . LEACHING RATES, SIDE AREA 2..5 GPD/S.F �- } 37 �� - BOTTOM AREA 1.0 GPD/SF Co - `s�4� SD LEACHING FACILITY + \-A-ZO S.s zti.o h �I ��r✓1� v it-xt,u4 = 1 sC3 F-k15T l V4 G sj ° z shy ��.,FG� -` " fl �- :�5, ,�,'F� r' •� ..� — sT •o� 2— ES + I13 >C I •D - �� P PLAN REFERENCE: Is, -LCC- 122422f� (UQ a �� \ / 1pZ• 3�( ASSESSORS LOT NO. MAP 2OB-- LOT -7 NOTE: SO (_�T •/� t `� SZ SS W I. ALL MATERIALS AND. CONSTRUCTION METHODS TO CONFORM WITH COMM. OF MASS. TITLE3L o gE ognrJflo�Eo„ tl) S.8 1<L_17--=`!= SO.00 ENVIRONMENTAL CODE La-T- 4 CZ L\ z• -c-o-r a e to _ �, of_7; PRdPOSt=:D LET LI1�! �( � �• T� t�� i t--tr 5F�E::P .-11(n-r EL kA _ice\,J1hTt=Z v � .Q $ `►�-"'�1°�4 S�ti?\IIG� 1 nr/�Tlnhl CT M�Ti=}Z_ . OF D ID. 91+y T'� 6� /SP�Lat�l 7h1J t=,17 . Lin\tJ ST ® 1 L � (n[ T UUN '•rt=IZIQ L.__ 5�P`T 1 P 1 tit` S / E FFss PLAN.Ei ice. 7E 1 F• 2C C: , SCALE I n t TEST PIT NO. 1 TEST PIT .NO. 2- ELEV. .S ELEV. _ 5 H-Z0 L Nfl- RtsER �" �( TL�1J'tG. C�n.nti � Sut3SO�L:. • Ike W 5 `{S'� CIS, Map, 5�tin o Loo►.� SOIL OBSERVATION PITS DATE OF TEST 6 6So1 L ENGINEER FI l IS TI-a I 1 S F�TtL 5. v o yS Z.S B.O.H.AGENT N IN_Q �'i c�r \cQ L_AQ G� .l �' r�1L 4S. MEb S�►�D EXCAVATOR ��T5H Pam'F 1n N ZO o o v �,� S'rpr�E MED. G�RwC� _ PERC RATE IN T.P. NO:_AT FT. �ZMIN./IN. I U r� ' ' 1,2 Sh.t�1 i7 S L� 4I 13 - (OLD 23' TP T=o�- �GrsC�-t- I`'T` S �' 'Z ►.lo wn.-r 36.5 s�r`,b ELLIS & THULIN, INC. LAND SURVEYORS AND CIVIL ENGINEERS EAST SANDWICH, MASS. 1_R-- N O �c-1�.-C ER. ?�.(o •_ lP�'�POS� �� 1�� SCALE HM ('-lo vErz. SECTION THRU SEPTIC SYScT Commonwealth of Massachusetts W Title 5 Official Inspection Form w _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 3 Pine Tree Drivel Property Address Pr„I Eric Funk " Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 .,„ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information , f j Q,3 0r on the computer, / use only the tab 1. Inspector. ` key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation rab Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13747 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-15-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use. at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �044 0; Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. CityFrown 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 was in working order at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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): a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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: 1 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 'h day flow t5ins•3/13 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 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well I If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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): 2 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. City/Town State Zip Code Date of Inspection D. System Information i Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? 1 ❑ Yes ® No Seasonaluse? ` ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 21 -0 6 25,000gallons 2015- 13,000gallons Sump pump? ' ❑ Yes ® No +Last date of occupancy: 6 monthsDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump unknown 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-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is Centerville Ma 02632 5-15-17 required for every 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 4 t5ins•3113 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 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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 32 Scum thickness 6 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 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. 1 Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No a Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3 Pine Tree Drive Property Address ' Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection with no sign of past backup or carry over. 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.): NA * 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-3/13 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 M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6'x4' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: t ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system i Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection. No high staining, damp soils or lush vegetation were present. Pit was dry with stain line '/2 way up pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A.1-14' B1-20' A2- 15'6" 82-15' A3-37' 133-32' A4-41' 84-44' B system In driveway (;1 3 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 3 Pine Tree Drive Property Address Eric Funk Owner Owner's Name information is Centerville Ma 02632 5-15-17 required for every page. Cityrrown 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: >12 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: Perk dated 6-25-86Date ❑ 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: Perk on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 i 3 Pine Tree Drive /G^M Property Address Eric Funk Owner Owner's Name information is required for every Centerville Ma 02632 5-15-17 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 i i I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Postal CERTIFIED MAIL,;��j RECEIPT uI (Domestic Mail Onlypo Ifisurance Coverage Provided) u'! Er For delivery information visit our website at www.usps.coms r9 OFFICIAL � 3 Ln CO Postage $ INA I$ru n, Certified Fee `��PN M90 O Postmark O Return Receipt Fee Here tS O (Endorsement Required) zo, o O Restricted Delivery Fee 4 " O (Endorsement Required) CO Total Postage&Fees $ i` PS r� r- Kimberly Y Pike & Brian D McCormick 385 Weir Road Yarmouth Port, MA 02675 Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: 0 Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. ■ 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 USPSe 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. ,- PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 � T � Town of Barnstable Barnstable Regulatory Services Department I Public Health Division m 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 3955 December 4, 2014 Kimberly Y Pike & Brian D McCormick 385 Weir Road Yarmouth Port, MA 02675 I ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 3 Pine Tree Drive, Centerville, MA was last inspected on November 17,2014 by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. (rotted and full of roots) You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER ER OF THE BOARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\3 Pine Tree Dr Cent Nov 2014.doc I, v http:lli sgl2f intranetlpropdataf ParcelDetail,aspx?ID=14614 �' F j? y li+re Search p • Application Center(3) ®Application Center(2) http--www,town,barnstable,,, Application Center ®Suggested Sites• Web Slice Gallery Favorites �®par� Detail B,tBN5TAiffirlc /I r• ,'�Logged In As: Monday,November 24 Parcel Detail 20;14 Parcel Info Parcel Developer a 20H274102 I lot LOT 48 I ! Location 13 PINE TREE DRIVE Pra — Frontage Sec Sec Road Frontage j --- — <,i Village CENTERUILLE I Fire DistC 0 MM s�l ract ; Town sewer exists at this 1 address Road Index 1266 Na Asbuilt Septic Scan: Interactive 208027002_1 Map Owner Info 9 ' Owner IPIKE,KIM Y&MCCORMICK,BRIAN D ]Co-ownerl Streetl 1385 WEIR ROAD I Street2 I S I City YARMOUTH PORT State KI Zip L2675L] CountLLI ry € Land Info Acres 0.14 Use Single Fam MDL 01 Zoning RD 1 Nghbd 0106 J 100% ( !:ISEPTICtiConditionally... 3 Pine Tree Dr Cent Nov,,, ;i Parcel Deta1 Windows L.. 1 L 17 AM 5tart11- 1 V u Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NT (5.1) o bE n e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive I Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 page. Citylrown 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, \\4 use only the tab 1. Inspector: "�J key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State , Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)'. The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/17/14 _ I spector's Signature Date The system inspector shall submit a copy of this inspection.report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system 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. r( t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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: The system consist of a 1000 gallon h20 concrete septic tank a concrete distribution box, and a 6x8 ft concrete leach pit.The tank is in good working condition with no signs of leakage. Both inlet and outlet tee's are in place. The liquid level in the pit has never been within more than 22"s of the invert and is still in passing condition. I _ 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): The system consist of a 1000 gallon h20 concrete septic tank a concrete distribution box, and a 6x8 ft concrete leach pit.The tank is in good working condition with no signs of leakage. Both inlet and outlet tee's are in place. The liquid level in the pit has never been within more than 22"s of the invert and is still in passing condition. ( Distribution box is rotted and full of roots ) t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma' 02632 11/17/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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 %day flow t5ins•3113 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 ;M Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17114 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT.due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the.system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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 I ❑ ® 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: ° 2 Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 s Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M Kimberly Pike Property Address , 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system consist of a 1000 gallon h20 concrete septic tank a concrete distribution box, and a 6x8 ft concrete leach pit.The tank is in good working condition with no signs of leakage. Both inlet and outlet tee's are in place. The liquid level in the pit has never been within more than 22"s of the invert and is still in passing condition. ( Distribution box is rotted and full of roots ) Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El ® No information in this report.) E. Laundry system inspected? + ® Yes ❑ No Seasonal use? El Yes ❑ No Water meter readings, if available last 2 ears usage d 2012 16,000 9 ( y g (gpd)): 2013 18,000 Detail: 47 gpd over two years. Sump pump? ❑ Yes ® No , Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) " Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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: 28 years old Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: k 18"s 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.): Vented through the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft 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 Gallon Sludge depth: 3"s t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c� Kimberly Pike M Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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 24"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No pumping required at this time. tee's and baffles are in place Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El'other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ' Date t5ins•3/13 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 Kimberly Pike M Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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.): Liquid levels are normal and pit shows no staining higher than within 22"s of the invert 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 L�5,ns13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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 Needs to be replaced. (Rotted and full of roots) 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.): Needs to be replaced. (Rotted and full of roots) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 z Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma. 02632 11/17/14 page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 1,000 Gallon ❑ 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 signs of hydrualic failure, break out or pondinq d { 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 y i! Dimensions of cesspool t Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 <f\,, Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is Centerville Ma 02632 11/17/14 required for every page. CitylTown 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.): No signs of hydrualic failure, break out or ponding. Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 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 1 ' 37�_ 0 , I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike ` Property Address 3 Pine Tree Drive Owner Owner's Name information is required for every Centerville Ma 02632 11/17/14 page. Cityrrown 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: 12+ft l 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: v ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: local usgs maps show the nearest open water venue well over 30ft below lot elevation You must describe how you established the high ground water elevation: local usgs maps show the nearest open water venue well over 30ft below lot elevation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Kimberly Pike Property Address 3 Pine Tree Drive Owner Owner's Name information is I required for every Centerville Ma 02632 11/17/14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION E Property Address: 3 PINE ST. CENTERVILLE MAP 208 PAR 027 L 48 Name of Owner JANE DRISCOLL - Address of Owner: SAME i 4 �(• Date of Inspection: 8/12/99 C ,7 9 O Name of Inspector:(Please Print)JOHN GRACI e!5 b I am a DEP approved system inspector pursuant to Section 15.340 of Title.5(310 CMR 15.000) o 9`99 Company Name: n/a Mailing Address: n/a t Telephone Number: n/a Z ik t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is Needs Further Evalliatind, By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:8/13199 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.I 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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SEPTIC TANK NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced Wa The system required pumping more than four 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 revised 9/2198 Page 2 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12199 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. ti 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa-(approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) i Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8112/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No , X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. 4 E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The ovyner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No I X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12199 FLOW CONDITIONS RESIDENTIAL: Design flow:-M g.p.d./bedroom. Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN Flow: 220 Number of current residents:4 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: iVA COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: Wa gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): 1!Q Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: Dia OTHER: (Describe) n& Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):I1LQ If yes,volume pumped nla- gallons Reason for pumping: nLa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wa APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATELY 15 YEARS OLD Sewage odors detected when arriving at the site:(yes or no) NQ b revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 BUILDING SEWER: (Locate on site plan) j Depth below grade: 2LE Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: 2 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: E Distance from top of sludge to bottom of outlet tee or baffle: 22" 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: fEl How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:ltla Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 f TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: Wa Capacity: Wa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:jita- Alarm in working order:Yes_No_ NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM IS FUNCTIONING PROPERLY PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: QNE leaching chambers,number: _nLa leaching galleries,number: 1)La leaching trenches,number,length: nLa ! leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: j3& Comments: ` (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY-SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) ! Number and configuration: Wa Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: nLa ' Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) BLa PRIVY: (locate on site plan) Materials of construction:Wa Dimensions:nLa Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a A O 0 I c. , 0('31 revised 9/2/98 Page 10 of 1 i ^ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 PINE ST.CENTERVILLE MAP 208 PAR 027 L 48 Owner: JANE DRISCOLL Date of Inspection:8/12/99 NRCS Report name: nLa Soil Type: WA Typical depth to groundwater: n& USGS Date website visited: Wa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps ' _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS r revised 9l2/98 Page 11 of 11