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HomeMy WebLinkAbout0085 PINE TREE DRIVE - Health 85 Pine Tree Drive, Centerville = 188 - 054 I IN UPC 125-34 No.2�OR �uK' HASTINGS.MN cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form lio Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive ✓ Property Address Todd Link Owner Owner's Name information is required for every Centerville Ma 02632 9-14-2020 _ 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 /419(e0 on the computer, use only the tab Daniel Hawkins key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 Q. Company Address Sandwich Ma 02563 A At City/Town State Zip Code ipcca (508)477-0653 S114324 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 Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Date:2020.09.1515:22:32-04•00 9-14-2020 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 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. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 0 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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: The system was in working order at the time of inspection. 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): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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): 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 Y Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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 P 9 9 q to or less than 5 m provided that no other failure criteria are triggered. A co of the analysis must PP � P 99 PY Y 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 ❑ El clogged 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 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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 ❑ O Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ O Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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 ` F 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.] ❑ El 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 CM 16.303,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 t5insp.doc-rev.7/26/2018 - Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question,in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ El 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? E ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: El ❑ 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 Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 4 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440GPD Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes G] No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑. No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2019- 116,000gallons 2018- 184,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: 9-5-2020Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 ti Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?• ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 3 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ED 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: Leaching upgraded 1997 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 111011 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive u Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): n 10 Depth below grade: 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 1 Dimensions: 000gallons 511 Sludge depth: 3111 Distance from top of sludge to bottom of outlet tee or baffle 4„ Scum thickness C 11 Distance from top of scum to top of outlet tee or baffle V 1311 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence_,of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and,should be pumped every two years for maintenance. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form (. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is required for every Centerville Ma 02632 9-14-2020 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): t 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �p Title 5 Official Inspection Form �} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): orr 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 J c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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.): NA * 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: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: (5) infiltrators El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town Satet 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.): The SAS was in working order at the time of inspection. Leaching had 3" of ponding when viewed. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts p Title 5 Official Inspection Form l." i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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 TOWN OF BARNSTABUa �— LOCATION S_. e oa: SEWAGE# �T7� VILLAGE CP.uy 7°L"1`//f�1te' ASSESSOR'S MAP&LOT ZeK=&1?.S`y INSTALLERS NAME&PHONE NO. SEP=TANK CAPACITY LEAaaNG FAcnxry:(type)1Z; • ,- s_ (aiso) /a. W,0' NO.OF BEDROOMS BUILDER OR OWNER B /E Ry(- PMtMITDATE: f®—`r—?? COMPLIANCE DATE: 1 d -17-9 7 Separation Distance Batween tba: Maximum Adjusted,{3touudwater Table and Bottom of Leaching Facility F Private Water Supply Well and Leaching Facility (If any wells exist on site or within 2W fact of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist .within 300 feet of leaching facility) ! Feet Fumished by a t AIL t � sly r y � I O Nt.&- c r 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form f. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar ❑■ Shallow wells >5' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Z Obtained from system design plans on record COC dated 10-11-1997 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: A field card on file at the local Board of Health was used to determine high groundwater. t Beforejiling this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 85 Pine Tree Drive Property Address Todd Link Owner Owner's Name information is Centerville Ma 02632 9-14-2020 required for every 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.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No./ L — �p Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpficatiou for Vsposar 6pstrm Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System NJ Individual Components Location Address or Lot No. S S plN& TpeG bki0( Owner's Name,Address,and Tel.No. CG,j-QMv1LLC WIL_IAK G�kISLOVL4> Assessor's Map/Parcel s I N E T 4Z_ Z,-*JTt:Z 1 L4;6 Installer's Name,Address,and Tel.No. $D$>417 19g`7 7 Designer's Name,Address,and Tel.No. Ce!<66 t_D& -G15-4 S / Type of Building: 6 Dwelling No.of Bedrooms Lot Size 3 O, q a St sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Heajkk / gned Date "oZC7l Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Of'� Date Issued ,.�r a No. �q —��f/p Fee p V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication.for Disposat 6pstem Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑Complete System NJ Individual Components Location Address or Lot No. 8 5 P! vC— 7-9EE 10JUC Owner's Name,Address,and Tel.No. W Ic. IA#A 1Rk l5x� Assessor's Map/Parcel CoaJT�'QVl $ 1 NC TRb �--, itp VI L4.6 Installer's Name,Address,and Tel.No. '$p$-417-)9 7 7 Designer's Name,Address,and Tel.No. CAO&LOt-D& *,JT 111SE'S � /� 6 Type of Building: Dwelling No.of Bedrooms Lot Size 3 O 9 g!sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Y Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in . t 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 Hea4k. ' 'gned Date :R 9'a0( Application Approved by Date Application Disapproved by Date _y for the following reasons Permit No. �3G'fL/ `^L)�R-6 Date Issued --------------------------------------------------------------------------------------------------------------------------------------- �� Th E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by Cr�4 PC-wfDE �!J rP,C1S� �.� at P(IIjF j p L^L.C�has been constructed in accordance } I with the provisions of Title 5 and the for Disposal System Construction Permit No ��/ ��.�dated Installer O—APe (06 E&ZrT 21,S;E5 (.C�, Designer N/A #bedrooms A Approved design flow gpil O The issuance of this permit shall not'Le construed as a guarantee that the system will function as designed.,, �r Date I T� +'F nspector )(�l A 1 L -•r - �( 11- ii(.�( � . y / l - !� - r - - - - 1-------------------------------- No. v C~�/ Fee ,f THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pztem Construction Permit � Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at 8 j 1�l JU[.= -T2 EC' D R 1 V 45 GE&j7-E&0[ (_6' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must a completed within three years of the date of this peirrmit. Date Approved by'__ r3� qA 5, j i r � oo .............. r q D;,00 �- J I a F I r r I ss'$ � a _. >%0 41 �V.)) J S 0 � � 5 (J C�J Steil., �J � +ug 241402:47p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form: Not for Voluntary Assessments 85 Pine Tree Drive property Address Dorte and William Griswold Owner Owner's Name information is �4 MA 02632 8-22-1 Centerville required for every State Zip Code it ac n Date of Inspection page C inspection results must be submitted on MIS form. Inspection forms may not be altered in any way. Please see completeness checklist at;the end of the form. Important:When A. General Information 's VV``"�(� Irr �' the out forms on on the computer, �� �2��• ���% use only the tab I 1. Inspector: , � ='go: JAMES key to move your cursor-do not James D.Sears use the return Name of inspector key. %.�i-'•cF ���', .� ey. Ca ewideEnter rises,LLC ; Company Name ����� nn _ nn of 153 Commercial Street Company Address 2649 Mashpee MA Zip Code remn CitylTown State Co 508-477-8877 _ S1623 Telephone Number License Number i 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i 8-22-14 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. t5ina•3.113 Tile 5 official Inapeaon Farm:Subsurface Sewage Disposal S !am•Pape 1 of 17 I Aug 2414 02:48p p.2 Commonwealth of Massachusetts_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is required For every Centerville MA 02632 8-22-14 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 is a1000 Gal.Tank D.Box and five infiltrators, 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): tsins•303 Title 5 Official I^speKion Form:Subsurface Sewage Disposal system•Page 2 of 17 Aug 2414 02:48p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name informations required for every Centerville MA 02632 8-22-14 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(cant.): ❑ 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 wetiand or a salt marsh t5ins-3113 Title 5 Official Inspection r-crm:Subsurface Sewage Disposal System•Page 3 of 17 Aug 2414 02:48p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is required for every Centerville MA 02632 8-22-14 page_ Citylrown 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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a 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 Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in his less than 6" below invert or available volume is less than Y2 day flow A Ul?11ifvG t5ins•3f13 Title 5 0fricial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I t , I Aug 2414 02:49p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owners Name information is Centerville MA 02632 8-22-14 required for every _ — page. Cityrrown State Zip Code Date of Inspection S. Certificaflon (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. 15111s•all Tifle 5 Official Inspection Form:Subsur`ace Sewage Disposal System-Page 5 of 17 Aug 2414 02:49p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form a' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is Centerville MA 02632 8-22-14 required for every page. CityfTown State Zip Code Date of Inspedion C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? '❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms); 440 tSans•3H3 Title 5 Mist Inspection Farm:Subsurface Sewage Disposal System-Page 6 of 17 Aug 2414 02:49p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments kvj 85 Pine Tree Drive Property Address Dorte and William Griswold Owner owner's Name infoTmation is requireequired for every Centerville MA 02632 8-22-14 page. Cityrrown state Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and five infiltrators. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 � Y 9 (gP ))= Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day d Y�9P 1 Basis of design flow(seatslpersons/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, 6 available' t5lns•3113 Tide 5 MOW Inspection FOrnl:Subwrrace Sewage Disposal System-Page 7 of 17 Aug 2414 02:50p p.8 Commonwealth of Massachusetts t^ Title 5 Official Inspection Form l -- II Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is required for every Centerville MA 02632 8-22-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: 05 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): 15ins•31;3 Title 5 official Inspection Farm:subsurface Sewage Disposal System-Page 8 of 17 Aug 2414 02:50p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive _ Property Address Dorte and William Griswold Owner Owner's flame information is Centerville MA 02632 8-22-14 req uired for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: 1997 Permit"97-570 New D Box 8-14. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: eet Material of construction: ® cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc_): Pipeing is cast iron house to tank. Other pipeing is 4"PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 8 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 311 t5ins.3113 Title 5 Official Mspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L Aug 2414 02:50p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form lg-I;,- u Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owners Name information is Centerville MA 02632 8-22-14 required for every page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 1n Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape 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.): Tank and covers at 8" below grade. Inlet baffle, outlet tee. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal El 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•3113 Title 5 Official Inspection Form Subsurface Sewage Dgmsel System•Page 10 of 17 Aug 2414 02:51 p p.11 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is Centerville MA 02632 8-22-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5ins•5/13 Title 5 Official Inspecllen Form:Subsurface Sewage Dispcsal System•Page 11 or 17 Aug 2414 02:51 p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is required for every Centerville MA 02632 8-22-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 — Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-16" Below Grade. W/Cover at 6"one line out Box is new 8-14. 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). R. If SAS not located, explain why: t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Aug 2414 02:51 p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner owner's Name information is Centerville MA 02632 8-22-14 required for every _._ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -- - Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is five infiltrators. Ck D Box and camera out to leaching. No sign of over loading or solid cant'over. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Tdle 5 Oftal Inspection Four:Subsuffew Sewage Disposal System•Page 13 of 17 ;w Aug 2414 02:52p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form M - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is required for every Centerville MA 02632 8-22-14 page. Ctty/rown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins-3113 Title 5 Official Irspection Form:Subsurface Sewage Disposal System-Pape 14 of 17 i I uy w �vi. lUG1 p.1 � Commonwealth of Massachusetts _ Title 5 Official Inspection Form d Subsurface Sewage Disposal 9 p al System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner O information is wners Name required for every Centerville MA 02632 8-22-14 page. Cityffown 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 t4 A � i 0 l A-A;.29 0 13-3 s,. 4 y- 3a f5ins-3M3 Tde 5 official Inspection Fonn:Subsurface sewage Disposal System-page 15 of 17 Aug 24 14 02:52p p.16 � Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name informations Centerville MA 02632 8-22-14 required for every _ page. cityfrown . State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 8+ 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: Past Report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground wager elevation: Per past report water level off bog rear of lot 8'. Bottom of leaching at 4'below grade_ Bottom of leaching at 4' above bog level. Before filing this Inspection Report,please see Report Completeness Checklist on next page. ' t5im-3r13 * Tit's S Official Inspection Forth:Subsurtam Sewaga Disposal System•Page 16 at 17 Aug 2414 02:53p p.17 M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Pine Tree Drive Property Address Dorte and William Griswold Owner Owner's Name information is Centerville MA 02632 8-22-14 required for every page. Cityfrown 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, . 7 t5ins•3113' 1`k_ Tide S official Inspection Form:Subsurfaoa Sewage Disposal System-Page 17 of 17 y a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SystemForms Not for Voluntary Assessments M Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for g every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information 4 forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-428-1779 S1 12855 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 L A-A 0( August 13, 2012 Job# 12-126 I pector'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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is g required for Centerville MA 02632 August 13, 2012 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: Recommend pumping tank. Leaching system shows no evidence of surcharge or saturation. 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. 7 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): i l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13 2012 required for 9 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if x the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is 9 required for Centerville MA 02632 August 13, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: R 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for 9 every 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. e ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ww 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is g required for Centerville MA 02632 August 13, 2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is 9 required for Centerville MA 02632 August 13 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? . ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: s Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) x 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: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown • Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons r. 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): t. - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is required for Centerville MA 02632 August 13, 2012 every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching system installed 10/8/97 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan).- Depth below grade: 1 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: 8"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years - Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. ' Sludge depth: 4" t5ins-11/10 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 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for g every page. CitylTown 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 26 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? 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.): Liquid level was found at bottom of outlet invert and tees were intact Recommend pumping tank Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is required for Centerville MA 02632 August 13, 2012 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.): 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.): l *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13 2012 required for 9 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): - If SAS not located, explain why: y . t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for _ g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 'Five Infiltrators ❑ 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.): Stone and soils surrounding infiltrators were probed with no signs of saturation or hydraulic failure found. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for g every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is required for Centerville MA 02632 August 13, 2012 -----------...-----------.._... ------ ----- every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately . r r r r r'r+rrr r+r ++r••r +'!+'r•' r+r+r r r r r r r r r r r r r r r r r r'r+•r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r ! r r • r r r r r r r r r ! ; r r r r r • r r r r r r r r r r r r r r ra 22 42 31 u,. 41 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13 2012 required for g , every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8'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: Water level in bog at rear of property is lower than SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. y t5ins•11/10 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 w 55 Pine Tree Drive Property Address William Griswold Owner Owner's Name information is Centerville MA 02632 August 13, 2012 required for 9 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 M TOWN OF BARNSTABLE �— LOCATION �� � � Tl�� �/�, SEWAGE # VILLAGE C& 1'Xr111AP ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. BD/TOL®r�l C4/1c5,y 77�`'�3�f SEPTIC TANK CAPACITY O f i LEACHING FACILITY: (type).�f ra�`" S (size) /Q X00 NO.OF BEDROOMS BUILDER OR OWNER A koa L CIIA Ae PERMTTDATE: lja COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �t 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 1 T O yj b r I No. ;-) Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ys PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for 10igw6al *pftem Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade/Abandon( ) ❑Complete System lJ Individual Components Location Address or Lot No.r,5-10/#ei /./7ee 9A Owner's Name,Address and Tel.No. G Assessor'sMap/Parcel p/&�1,vV1f Installer's Name,Address,and Tel.No. �G 1 C`- 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 /f gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank �X1"5li! Type of S.A.S. /O 4'qgQ 7— Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued y thi B d eal Signed Date IP T cr Application Approved by Date fin— ay ^ ! 7 Application Disapproved for tY follo ng reasons Permit No. —2 - S 7n Date Issued If No. Fee _ f Entered in computer: THE,COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE., MASSACHUSETTS Application for 33i,5poga1,*#5teM Cone;tructton Vermtt Application for a Permit to Construct( )Repair(,�)`Upgrade'(�')Abandon( ) ❑Complete System ©individual Components Location Address or Lot No. ��� Owner's Name,Address and Tel.No. Assessor's Map/Parcel G e Devi Ile Installer's Name,Address,and Tel.No. /G Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/Z%07 Other Type of Building ems/ e' t e No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ZO gallons per day. Calculated daily flow yy� gallons. Plan Date 4 Number of sheets Revision Date Title .Y/5�'`//f Size of Septic Tank l= % Type of S.A.S. l0 Description of Soil A Nature of Repairs or Alterations(Answer when applicable) T/7-/e' Z ' 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 Certifi- cate of Compliance has been issued y thi B/7d - Signed ` �/ � Date Application Approved by Date J Application Disapproved for He folloxWng reasons "f Permit No. J O Date Issued THE COMMONWEALTH OF MASSACHUSETTS / 4V, BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE TIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(1/) Abandoned( )by e0fle4 _Ifll CC�sr�T. at J�_ ���e T ee ,o . G ee�?��'v� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this ermit s ad}not be c j trued as a guarantee that the system it tion as designed. Date �a - ! ' / / Inspector J1 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miqu al &p5tem Construction Verna Permission is hereby granted t9jConstruct( )Repair )Upgrade(✓)Abandon( ) . System located at K.S //�a� ZZee Repair e7e/;/rff I I('/11� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: �� Approved by r TnWt-OF BARNSTABLE LOCATION g� AilY e T�Pi��' /�, SEWAGE # 7-5,7e VRIAGE Ce# i^�/1//P ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. BO/'TOLO7t`I CO�S.r. 7 v`�3�p SEPTIC TANK CAPACITY L;BAt,HING FACILITY: (type) f, �+7� s (size) /Q x y0 /62 N.O.QF BEDROOMS _ BtMDER OR OWNER S A- Ret L CC 14 PER;MTTDATE: /O ' 7 COMPLIANCE DATE: i Se oration Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �r 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 - Fgrtusfied by T.. f 'J� `�� y �11 o y' �.. I � ,1 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PL NS) T. Oi°!'T ®/ .4� j�'zerebv cerrir:that the apniication for iisposai wor,,75 cons- cticn permit sinned o�� me gated /0/7le7 -hle repeat-r located at 116%ye- T-If 4e 40e. ~iet,z foilowing c reria: V/__ %v e:! 0 A ✓,""v_ `.�`- -'Dim .- - " - - "__:�. _ciG`.• -' .�i. ,: -...: .c�_- - -- _ �rGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER rN THE TOWN OF BARNSTABLE N- UNMER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified,plot plan. this plan should be submitted]. y,;t-t.c••�� JY9- t y r �,.J;•'�i.�.P f 'k. ..Y J ,#` � �:. c''i."-,v. s.. '� ay"' �yl � "i �^ a,!,,•��� tr, � �i�4ar� �.,- �. � �,, � ��w r r ;.�- m•: n%� �' .�'r