Loading...
HomeMy WebLinkAbout0179 PLEASANT PINES AVE - Health (2) 179 Pleasant Pines Ave Centerville F A = 233 062 n /2Pend t/o a ES im 1521/3 ORA 100/6 P2 No. Fee THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Mie;pogal bpgtem tongtructfon Permit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot N . Owner's Name,Address and Tel.No. �79 �l�As�.✓7- f,�� �F 11'-,.r 9 ✓"r L sY /a Y Assessor's Map/Parcel _3 Installer's Name,Address,and Tel.No. Designer's Name,Adjje ss and Tel No. �/2�� f`D 7 > 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date. Title Size of Septic Tank Type of S.A.S. Description of Soil a ' 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 iss d by this Boar lth. ,. f. Si ned Date Application Approved b Date Application Disapproved for the following reasons Permit No. �5 Date I� 5 7 ssued 20 � =, No. �- ' Fee 400 40 sit a. ,�,,.iT•-?' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN�)F BARNSTABLE, MASSACHUSETTS ZIppYication for Migpoal *p5tem Cou.gtruct on Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components • . Location Add re r of Now��A r ���¢ rl�,, Owner's ame,Address and Tel.TrJo. i /� S A ✓ C Ex,17Ee v ur is ra.✓�f L 4f IF y Assessor's Map/Parcel ^� 3 A 6 F d— Installer's Name,f�d/Ldess, d Tel.jo. Design�eis,�Tame,Addrgss and el.�o / 1 �yC� Li SJ "c E Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.'of Persons Showers(. ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil , R "Nature of RepairsorAlterations(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���thisd-ef-Health ' :n Sig ed �—"" Date /,/� ' �S Application Appro�ed by _ Date ,q Appl;6tion Disapproved for the following reasons Permit No.` �5 Date Issued 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, tha e On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded( ) Abandoned( )by /.9 g"e t t at 7 has been constructed i accor ance with the provisions Title 5 and the for Disposal System Construction Permit No C900 S S 1_7 dated a l 7 S Installer G Designer- Ste I The issuance of this permit shall not b.,-,co/ns�tr ed as a guarantee that the m will f c i s esigned. t' - Date ��/�r, Inspector- --------------------------------------- b .' No.- _ �- Fee- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS w- Mie;pogal *pztem Con!5truction Permit i Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) 1. System located at 7 C �� (-?e�w 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 rpust b comp ted within three years of the tee of this pe it. Dater 7 Approved'b a.. { FROM COMERCIAL BANKING �ONTROLLERS,,OFFICE (MON) 9. 12' 05 9.21Q. 9,24/NO. 4862781487 P I b --O'➢`�200$ S 1iO s 28a OTAICLAIM DEED Property Location: 179 Pleasant Pines Avenue,CeateM11 ,MA 02632. We.FRANCIS W LAAEY,aWa FRANK W.LAMY,ai kd FRANCES W LAHEY,of lag Pleasant Pines Avenue, Centerville,Musachusetu 02632,foi,nominal consideration of less than $100.00 grant to ourselves FRANCIS W.LAAEY and FRANCES M.LAHEY,husba rd and wife,as ummts by the entirety of 179 Pleasant Pines Avenue,CenteMllc,Nfas=hu sells 02632, with QUITCLAIM COVENANTS Those three certain parcels of land with the buildings dureon situated in Centerville,Barnstable County,M Wwhusetts,further described as follows: Being sboa►n as L01' 1.LOT 2 and LOT 3,on a play 'tled''Subdivision Plan of Led in Centerville,Buumble,Massachusetts,for the E.P.C.; Scale 1"=50'.May 1970. Barnstable Surrey Consultants,Ine,,West Yarmouth; ette.which plan is recorder]at the Barnuble County Registry of Deeds in Plan Book 238, 59; The above described lots are conveybd together 'tha nd subject to any and all rights of way in,over and upon the ways as shown an said plan d s ject also to any conditions quad restrictions of record insofar as the same may be fn 4nd mpplicable. Said lots are also conveyed subject to a utility t to the Cape dt Vineyard Electric Company and the New England Telephone and Telegral h Company,remded in said€ egistry of Deeds in Book 1390,page 386, For Grantor's title to Lot 1 see Book,1480,Pepe.579; or Lot see Book 2212,Rage 48; and for Lot 3,w Book 2132,Page 153 of the Bmstable Coi mty Registry of Dec& FRS.' VOMERY i A L UPKI NG COMTROLLERS' OFFICE fMOIN j 9, 12' 051 9.24,/ST. 9,20G. 4862781487 P 2 ` SM our his and s is jjhis day of n t, 5 rot :;(� M. c;� I ' A41 FRANC FRANCIS W, JAMy, a ka Of FKANK W. LAMEY rd ES K LAY iy y Cheryl L, Lqjko By Cheryl L.L 'ko under Power of ey u4da lower of A4 °icy Xe f tea 41 �srss 7.dri-ia a s a k a'd�rd�NK 'sa. 5..._-4— `a� g '��e p!` Q,�' t w, .-,�'t- ;.. ,'g`�,;—.a Ity� ,gam __-_ iw —al&Y-L Fwt xdilat!v vv T-'£ ={ 7 a, Sv;ELSE`- -4r?EiCe>f,4 A 4 '" {� .e _- i v3 nd-- Es!°51 d x_E - -o i s i i t tl7S SSGi Ra a - 4 Y 'L 6h sc �ll� '•}b114� • iaf6:a di�i�iiRf"aLlfV F,��S�P?f 3n�P arm �g ems, m2 �._ 2 ?E-E-f3 1:::_ �..-�Fa:n�e_!L7'�•y,•�;;•ve r..n; �� ar...�;..- n 3 .v�g � j !wQ &L.EUjbri Liz ,£�4t�^�ca�4 f L� F }�6�n4'-f �'6.F?�t�P F� EF F �Pt?e?t_ ns Yi's�SYcSSs a,3 F bR�`e dam, ,Igr& __ 4 f L' Y �'-�--^ P %1_T''A a—8''-3'f'�'__T P'.t°?Y.'G'yy�P.8 P2'�?Y - see.._t+E ��y-_Cy �y�y �yy�y ggg_ �q�}� p--aEa bib m5-- d;��y ia"3�s-it <eVJ�Y�iiLii y?s° f�•3Y avilden gab i s ie�i-•-�.of d rrQ�Wers r, t -_ --'-' s.r. _e'"e af�S A�{��I.'_•.19c ic¢ a3 �,� S eJe¢6_. _..-.-._9r�....�.y�z..._rc�E.._ ecY.as�6...w.'•:R'M1.r_�..�.5..'�L' ¢l.'^`' `T^`'S"�6�..�.X F.p_.. -_-_ _UM I `s el 1 is LI& f'ifp fti-S_'f`% Fik 171f.f my commsion apt or, FROM n.O MERCI AL on ANKING CONm RO LLERR OFFICE (MON) 9. 12 G5 9:25AS T, 9:200, 486278148r P 3 COMMONWEALTH OF M SSACHUSET TS PLYMOUTH COUNTY, SS Y14 2005 Then Personally apPeared before me the undersigned not Uy public,the above` d Cheryl L. Lojko aftmey in fact for Francis VV, Lacey a/kJa Frank IV. L,shey and Fraatoas Prl. LAY under powren of attorney who proved to Me through SStisfkdOrY evidence of ideatifcatiou, wb'ch were to be tbwperscm whose is s"SlIed`C`E the Preceding C9g attiched 40OttIneot3v the she i volmmap-.1yPry its tstiE :d m-'nf"_ ... I j'A-U ilk y wall; le- F, f L.E 7g!!!4l4Si gt�.rvetlra+• d !Jr � I a. r f . 1 i I d` ' � I I ' i }, I i I Town of Barnstable Regulatory Services sM Thomas F.Geiler,Director NAM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 O ' e: 508-862-4644 Fax: 508-794-6304 Installer&Desianer Certification Form Dale: De 'per: IS f �9. 1. Z-A' �-installer: T Ad ress: - Address: On; was issued a permit to install a (date) (installer) sep;is system at l?9 based on a design drawn by (address) (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. r u �1►�'���N OF�Ass9 yew HARRY yG c EARL m (Installer's Signature LANTERY, JR. y ,o -p No.26575 Q AL (Designer esigner's ignatur (Affix Designer's Stamp Here) PL ASE RETURN TO B STABLE PUBLIC HEALTH DIVISION. CERTIFICATE O F COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- WITMHKYOU. CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION Q:I th/Septic/Desiper Certification Form TOWN OF BARNSTABLE �= ,� _ S"i 7 LOt�AT`•ON �� �l � s A f S — SEWAGE #ECG S` VF.LAGE C ^' 2 411 Zle- ASSESSOR'S MAP & LOTa 3 3 I;sSTALLER'S NAME&PHONE NO. So Y SEPTIC TANK CAPACITY C- X r.ST /oa a /o O6 1:2,0 LEACHING FACII.TTY: (type) De GVS r Sys i 1 M (size) S X Q-d k NO. OF BEDROOMS_- _ BUILDER OR OWNER f—k A ✓"r PERMIT DATE: ////77, 0 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 33 _ -13 �3 I,-�D Ate/ t-,�./ OB �ae� 0?-7,-S'' a. L SOS J3G ;Jza. s- LIB=cTRic 3 Y i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 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 forms on the computer,use 1. Inspector: —•hHl—( �/�� only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number 4 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. l 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 3/17/2011 - Inos'pector-s/signatt Ae 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 ashared system or; has a design flow of 10,000 gpd or greater, the inspector and the system ownershall submit the: report to the appropriate regional office of the DEP. The original should be sentto 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. /I t5ins•11/10 Title 5 Official Inspection Form:Subsu face wage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every 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 septic system is in proper working order at the present time. 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•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 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction,is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/rown 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 1h 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 wM 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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.] El ® 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— IW PA) 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 r Commonwealth of Massachusetts W - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M ,•' 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y g (9p ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3/17/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ ' No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville . Ma. 02632 3/17/2011 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: System installed in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.no evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 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 Dimensions: 1000 gallon Sludge depth: 5" t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 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 27 11 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 179 Pleasant Pines M Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 1000 gallon pump chamber appears structurally sound.No evidence of Ieakage.Pump, floats and alarm are in proper working order. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 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 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 25'x20'x1' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Stone was dry at time of inspection. 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • • r • . . • ir-ItroLMM INK IBM �t t^ c z �- +• x 4. ,.� �Ti-� b`x ys�,, i.y' Y4a a.3 ?wron�'.'� 4�-r�, �+,�„e�S. d,a:w'L.4 `'F m 9"4rs., d %rib xa F `�,,,-f a.�g 4x"Tf �SMt Ia sr) d�"0 .,,f +.nnt `ia 5 ¢, 'H'''s' M.t.� iv<*" vsr .fwY.AZ Y X+.ti.,9{ � _ r,� • � f r •• 1 ' • . rr• -r. rr . r r r •r- � 1• . rr. .. 1 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 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: Bottom of leaching 5' 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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 } Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 179 Pleasant Pines Property Address Adam Hufnagel Owner Owner's Name information is required for Centerville Ma. 02632 3/17/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:, A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4� Gf ® 27�` =1 ,04 'a cr�,G ` -44�,,de-2 o TOWN OF BARNSTABLE LOCATION r" �i ,!�'�s'� d✓i �'t��ri� SEWAGE VILLAGE C > r2 G°r zle' ASSESSOR'S MAP & LOTS 3 3 - 6 INSTALLER'S NAME&PHONE NO. e-H Sc, r -?zz 13 a� SEPTIC TANK CAPACITY x r Sr /C o O v LEACHING FACILITY: (type) DoGv5 ref SYs?,,t1l (size)Z 1 Q.Cs,IC ! NO. OF BEDROOMS �- BUILDER OR OWNER �"� A ✓/r �A�:� / . PERMTTDATE: COMPLIANCE DATE: /0 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 Facilip,(If any wetlands exist within 300 feet of leachingfacility)ty) Fee t Furnished by TOWN OF 13A.I.NSTABLE E Pl6,S g H-f p' If 5 AV SEWAGE # L Cevt ter VII..LAG'E ASSESSOR'S MAP & LOT 233 T Y`- ALLER'S NAME&PHONE NO. . "t "( rn�.IL r SEPTIC TANK CAPACITY (0 00 LEACHING FACILITY: (type) Fte)d (size) NO. OF BEDROOMS BUILDER OR OWNER Eyonc t S La 4e Y PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If.any wetlands exist within 300 feet of leaching facility) Feet Furnished by LOCATIONS 1 20 Ft 17 Ft 2 22 ft 19 Ft (EACH FIELD z SEPTIC TANK A B EXISTING DWELLING # 179 I PLEASANT PINES AVENUE NOT TO SCALE Commonwealth of Massachusetts ,i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. � 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. CltyrFown 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 (jf known)and source of information: tank origanal Pump chaber and field 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2'feet Material of construction: E concrete ❑metal ❑ fiberglass ❑ polyeth lene y ❑ other(explain) 1000 gal H10 tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place no major decay or visable leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene 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 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 El 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 ,IF Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cltyrrown 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 contra ct(required). Is copy attached? El 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts j= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): pump was cycled to test each lateral in field. alarm float was lifted and heard audio horn from outside. pump has weeping hole *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: ® leaching fields number, dimensions: 1)25'x30' ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/1 g 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.): no ponding or hydraulic failure present. leaching is a dosing field. with 5 laterals all have cleanout caps at surface level. all were tested with good flow and quick drain back 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Official� Title 5 icial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cltyrrown 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 0 drawing attached separately l� I G � —E7 G 3 � P e, _�� �q_ - C5 � �f3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 J Commonwealth of Massachusetts �n p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 179 Pleasant Pines Ave U*� Property Address Atterbury Owner Owners Name information is required for every Centerville Ma 8/8/19 page. Cityrrown 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: 2005 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: leaching is a mounded system with dosing field system wasdesigned and installed 4'above high seasonal ground water(see engineered plan and town sign off) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owners Name information is required for every Centerville Ma 8/8/1 g page. Cityrrown 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 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form F+ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave i Property Address r� Atterbury ..;a Owner Owner's Name information is Centerville Ma 8/8/19 K "required for every page. City(rown State Zip Code Date of Inspection f, 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 51or�[f on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return key. Company Name 151 P.O.Box Address „� Company Address Forestdale Ma 02644 City/Town State Zip Code �eoan 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title Y p p e5 (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 8/8/19 Inspector's Sig ure Date The system in shall bmit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within 3 d 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 Commonwealth of Massachusetts ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. Cityrrown 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: No failure criteria was encountered during inspection. Tank was at normal operating level. pump chamber and alarm was tested and is working. Pressure dosing filed was probed stone is dry. end caps on field were removed 1 at a time and pump was cycled water each pipe received good flow and drained out quickly. House has been a summer-part time use with very little use per owner 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 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owners Name information is required for every Centerville Ma 8/8/19 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/1 g page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system Ely has a septic tank and soil � stem absorption s SAS and the SAS is within p Y 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 I well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L u 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/1 g page. Cityrrown 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 Y 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 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is required for every Centerville Ma 8/8/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? El ® 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 I Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owner's Name information is Centerville Ma required for every 8/8/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: seasonal 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 ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ® Yes ❑ No Last date of occupancy: current seasonal Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 i Commonwealth of Massachusetts - o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 179 Pleasant Pines Ave Property Address Atterbury Owner Owners Name information is required for every Centerville Ma 8/8/1 g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 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 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 Se wage Disposal System•Pag e r Town of Barnstable P# �® Department of Regulatory Services "szA Public Realth Division Date oZ/ 0 iM, �s$ 200 Main Street,Hyannis MA 02601 Date Scheduled t /g/© J Time Fee Pd._ Soil Suitability Assessment for Sewage Dis osal Performed By: r' LQ(\ A Witnessed By: k9CATION& GENERAL INFORMATION Location Address %.1<3k ]]J (( Owner's Name ` `J v 1 e, Address St3�rr nsL_ F-:tn NQ Assessor's Map/Parcel: .� Engineer's Name �- / NEW CONSTRUCTION ION REPAIR V Telephone# JgC? tsc% Land Use Slopes(%) Surface Stones JJ O Distances from: Open Water Body <, 3 Dp ft Possible Wet Area ) 0 of ft Drinking Water Well -� ft Drainage Way y ft Property Line J fc Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) yy�+ r Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal:High Groundwater HZ0 DETERMINATION FOR SEAONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole:_._ _ _ __in. Depth to Soil motticS: la. Depth toiweeping from side of obs.hole: -in.- Groundwater Adjustment fr. Index Well# Reading Date: Index Well level Adj.faetbr Adj.Groundwater Level .. PERCOLATION TEST Date„._. Observation Hole# — Time at 9" .__..._.. .w..---... Depth of Perc '�' Time at 6" Start Pre-soak Time.@ _ Time(91'•6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Hehlth Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCF�RM.DOC DEEP OBSERVATION HOLE LOG Hole# J Depth from Soil Horizon Soil Texture .Soil Color Soil Other 7- Surface(in.) (USDA) (Munsell) Mottling (Strucre,Stones,Boulders. Con Pstenc*X.% ravel l7 -44� o y R-10 5 0-7 .� C�M�A�� ► � y: i� 10yZ $ R�j 01 DEEP OBSERVATION HOLE LOG Hole#? Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. / Consistency,%Gravel) 2..5 J Ott]--IAL //I -'Z-)1c) 5 Z' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Conslstency,.9b Oravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi to ra el Flood Insuran je Rate Man: Above 5p0 year flood boundary No _ Yes Within 500 year boundary No— Yes Within 100 year flood boundary No Yes Depth of Natuially Occurring Pervious Material Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed fbr the soil absorption system? t,what is the depth of naturally occurring pervious material? Cgrtifkation c I&rtify that on r 1.Z (date)I have passed.the.soil evaluator examination approved by the Department of Environmental Protection a ,that the,above analysis was performed by me consistent with . the requi ining,ex a Ild exp �:a described in•310.CMR 15.017 k x S p :J Date gnatured` C 1?pTIG103RCFORM.DOC.. Ali sl1 Inc =; .. 4 , k i 1)%P ECOJECH MLE® INSPECTION ,ARCEL F �c� Environmental www.eco-tech.us "- �' THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 179 Pleasant Pines Avenue Centerville EEE Owner's Name: Francis and Frances Lahey Owner's Address: 179 Pleasant Pines Avenue Centerville,MA 02632 Date of Inspection: December 22,2004Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 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: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority X Fails Inspector's Signature • �S Date: Qe, 22' 2OOf- 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 Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22 2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: No I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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,or 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 breakout or high static water level 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 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 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 ND explain 2 Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 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 and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health (and public water supplier,if any)determines that the system is functioning in a manner that protects the public health,safety,and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed by 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 3 Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes" or"no" to each of the following for all inspections: Yes I have determined that one or more of the following failure conditions exist as described in 310 CUR 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 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 X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed by 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) Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 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 You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered "yes" in section D above the large system has failed. The owner or operator of any large system considered a significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeluding the SAS. located on site? Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: N Existing information. For example,Plan at the Board of Health. Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) [310 CUR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 2 Does the residence have a garbage grinder(yes or no): Yes—removal of garbage grinder is strongly recommended. Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 177 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no)_ Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Innovative/Alternate 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: System is assumed to have been installed at time of dwelling's construction in 1970—no records available at town hall Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 BUILDING SEWER_(Locate on site plan) Depth below grade: lft Material of construction: X cast iron _40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting, evidence of leakage, etc.) Sewer appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK: Yes (locate on site plan) Depth below grade: 18 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle: N.D. Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: N.D. Distance from bottom of scum to bottom of outlet tee or baffle: N.D. How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Outlet end was not evaluated as conclusive evidence of system failure was observed at leach field. Inlet end showed considerable solids buildup on top of inlet tee indicating a history of backup into tank Septic tank should be pumped dry at the time of system repair,and the interior of the tank should be examined for structural integrity. If the tank is usable a schedule 40 PVC outlet tee with a gas baffle should be installed. GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Date of last pumping: Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: _gallons/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order(yes or no):_ pumping:Date of last Comments:(condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: N.D. (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: N.D. Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) D-box was not evaluated as conclusive evidence of system failure was observed at leach field. A new distribution box should be installed at time of system's repair. PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 i Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 SOIL ABSORPTION SYSTEM(SAS): Yes (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 X leaching fields,number, 1 _overflow cesspool, number —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) An observation hole was dug into the stone comprising the soil absorption system. The stone exhibited a pronounced black staining indicative of prolonged effluent contact.Effluent was observed to be in the top laver of peastone. CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: none (locate on site plan) Materials of construction: Dimensions:_ Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 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'(Locate where public water supply enters the building) LOCATIONS A B 1 20 ft 17 ft 2 22 ft 19 ft LEACH FIELD 2 SEPTIC a TANK o A I B EXISTING DWELLING # 179 PLEASANT PINES AVENUE NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 179 Pleasant Pines Avenue Centerville Owner: Francis and Frances Lahey Date of Inspection: December 22,2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 5 feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked. date of design plan reviewed X Observed Site(abutting properly/observation hole within 150 feet of SAS) Checked with local Board of health-explain: Checked local excavators, installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. A survey instrument was used to determine the elevation of standing water in an adjacent wetland 11 z V,JEggoN 0z-r BENCHMARK: 5TAKEtTACK ELEVATION = 100.00' (A55UMED DATUM) F. 44.25' 1*03'46 S7144.38'W 57I°03'48"V✓ .� 344.38' APN 233 - G3 r �' 30,89E±5F � APN 233 G4 (RECORD) / 20,885 -±'8F DESIGN LOCUS (RECORD) �0) / SINGLE FAMILY DWELLING WJS, BEDROOMS LANpS LEACHING PIT TO BE PUMPED, NO GARBAGE DISPOSAL of ,ter -_____.._.._ . . . EXISITNG EDO f FILLED N1TH SAND AND ABANDONED / DAILY FLOW;= 110 X3=33fl G.P.D. SEPTIC TANK(VOL. REM) - 3'66G.P.D. X 2 - 660GALS / a o 1,000 GAL.TANK-O.K. (EXISTING) �4� \ SE 1E MOT C 13 7F 0 R PRE S S, :� ----- 9� / T__�)15T RU I E7 l U W ri Tlp 571°03'48'W 10 TEST PIT PERC. TEST " F o- �� / S ) oolocy Az r� � _ TO'r OF TANK ELEVATION 101 .00' TES: ,j _ � APN 233 - G 2 1 • DISPOSAL SYSTEM TO BE CONSTRUCTED IN.STRICT ACCORDANCE WITH EXISTING ) COMMONWEALTH OF MASSACHUSETTS ENVIRONMENTAL CODE -TITLE V. ��r_ DECK 0 L I r,1 __ -. U" GRADE6 2 2. ASSESSORS PARCEL NUMBER (APN) # # 28 485 ±SF c —1`0),0 � $ x I ,•�' No. 17g ' 3. CONTRACTORS TO CALL DIG-5AFE 72 HUURS PRIOR TO BEGINING CONSTRUCTION AND/OR EXCAVATION. � ✓ SAN�y ` l� ° ,o •� '� � ' �jLvz' ° \ I %P�, (RECORD) 4. EXISTING PITS TO BE PUMPED AND FILLED WITH SAND, AND ABANDONED. L o1�Nl `��'�' Z — D \ �WD. , ?-�- 5. CONTRACTOR TO FIELD CHECK INVERT OF EX15TING TANK L ogrn�) 98_� ^�- MNvfoL 15T FL. EL. = I OG.GO' � G. PUMP SEPTIC TANK, CHECK T"S AND INSTALL GAS BAFFLE L oAM I G� / '— 7. THIS PLAN DOES NOT, IN ANY WAY, REPRESENT AN ACCURATE, INSTRUMENT SURVEY OF THE PROPERTY, AND 15 NOT tsA' TO BE USED FOR ANY CONSTRUCTION, OTHER THAN THE ELEMENTS OF THE SEPTIC SYSTEM AS SHOWN. 8•° _ 25 I 8. TH15 PLAN 15 NOT A RECORDABLE PLAN. r ( i BA g. BENCHMARKBENCHMARKt�FD OBI AN.ASS LIMED DATtINA. AS 5NO�:NN. I)NLFSS r?THFI�.tAijFF �a��Ij=1�D I 10. SUBDIVISION 5URVED BY TOWN WATER L=8.00" � �!/' D BITCO 4C, �. . " =20.00� 11 N /� DRIVE��AY{�r I I .s(,�!�L-. t�P' Ea5t�1 �D`1_ T?UF� 1 �1 ,1�T�1 � <',�r 4v / � .LAT�:N') S t,�l�'1X ITI/2' / Z_ .00'1 L_ 154.34' :Z (? p� cL YA-�1" W1 1-'QI'1Y 2,3 R=487.85% o �� I /• a a � \ �,. '�'� \� 12. SURVEYOR: HOOD SU>ZVEY-GROUP, LLC:cq� -- 0 01 G J\A'CD ti V M - S Arl.D 1f \ STONE WALL FIRE 15 ROUTE GA St�r/D o00o HYDRANT SANDWICH, MA COARSE �"`\°� � 13:1�iSTi�US�i.=1Q)v D�S1GNa g G R P4 E L:" . �— EDGE OF PAVEMENT � •S O � rr Y �. 5 Lk7F_GALS WITH 114 rER 0�k'T10NS Q�.�S��c>�.►e� �*°s�,1-';'v r cArcn cArcn T3. LA 1 F_R N\_ D )t\. Ill c?�r•' -� BA51N BA51N C. I"t 1 'Q 31"v\V N\ I N -1 I N C— 1 NZ 5Sll�t 0 F �•, F 1 . }.►�� � PLLASANT AVEN U D. T l - V,M T . L Ate? —O,6.a G. MP\K FOLDS LE�JGT H - E x4 ft_ = 20jE_ US DI/\, or :o 5x25'=/25`nC1. OlJgS`� = 1`06 cf.x7, �}S TESTED 7. `li GAL, X 5 raf 0 39.5To 75 GAL. 2. a D05E3/DA- Y - 33 0 GP-2) 8 D P D = 42 CALE /D 5F PUM,F, v0)__ �z + c7. +S. 52. 6 G 3 A,Ls. SITE PLAN MIN_ DiSCH��RGE RATE :. 3,4 xs = 47 � PM� F1RiTOFLQo SC�LC = r � SM oF,�, L. To rinL L 0 S S G fit. i�" 1 cy M. PUm7? V N )T C ONE PUMP')- PLIMPIMC, H EAD = 5 -L fi 6f CLCSS�=Jls�:, TOP Fs�A a iY, , I N: PUMA' C)-1AMT31-T S 1 F 33�} GJ,L_ 133 GILL. = 3SS G/-1L3_ / S REMOVE IMPERVIOUS v LANTERY,jR. a •} �� C7 A L T/A W P, - 1Y.. K, MATERIAL 5'AROUND 3 M�X P No.mn 4 P U N1 P OFF: J" r-R Oro J-3 OTT cD M ` it ,2°I°SLOPE y�, FSS� NaL E�:,��' , ' P U 1A P 0 N ; G " +, ACCESS W%IN \ �.i��i?.� �i>.\ ice\ \i,\�l�\i��r?.\.�\`�\ 19, RE�TP,t N I N 6 W AL I-w��,�w A7 F-� SEWAGE SYSTEM D ES I G N 9"MIN.COVER W�i�Ea'ji C�}jT - TI-IRO711\IQ i pine �R v�.ovE ,j,r TIGHT LWINb- 00D "� — °oe000 FOR 1,000 GAL 99.7 M 99,5, .'L.. - HEALTH AGENT APPROVAL DATE M `R A N K LA -1 E Y .� H ► 9`3.0 P.C.coNc.` oN . ° ° ° I o3,3 ° ° 5 ° , � 2', P�A`�T IJk 17 9 P LEMAI.17 P I N F_ AVE. FIELD �s��.�;�,,. . } 0 2 �3 .`� 8°�$ b i C E N T L Tom' V 1 L L E M /a CHECK SEPTIC TANK(N- I0) GASBAFFLE OFF ba�$$0°a� ND �,,/ B �. ° ° °g �a° ° Y*m A E D ON ENr� 3i4' TOI liz"DoueLE` I� 9 PLEASJ-�l�T P11��AVE- �—G"CRUSHED STONE OR COMPACTED jv`A.NtrOLD WASHED STONE 10'MIN A PNJ �. . 5'MIN- 24 \,_- ' PROPOSED CONTOUR 20'MIN. ADVANCED TECHNICAL SOLUTIONS — DEPTH OF LIQUID-4' INLET TEE DEPTH- 10" HZ O BELOW / 10 EXISTING CONTOUR CONSULTING ENGINEERS OUTLET TEE DEPTH- 14" t3zg3 P.O. BOX 99 DRIVEWAY PROFILE OF DISPOSAL SYSTEM licit E. 5ANDWICH, MA 02537 � -Z�-c1�"SCALE: I"-�3�Ct' ( DRAWING NOT TO SCALE) FIRM ZONE DATE:a3o��� "B" f