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HomeMy WebLinkAbout0222 PLEASANT PINES AVE - Health 222 Pleasant enuE., , 234-002.002 Centerville . w 1 NO. 1521/3 ORA 10% 0 0 �i. �1� Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address FV. Paula King 222 Pleasant Pines Ave n Owner Owner's Name information is required for every Centerville V MA 02632 10/9/2Q f 8 page. -Cityrrown State . Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imng out forms n A. Inspector Information S�� a filling out forms p � LI®/, on the computer, use only the tab Joseph M Martins key to move your Name of Inspector cursor-do not Accu Specheck use the return Company Name key. 17 Northside Drive r� Company Address South Dennis MA 02660 City/Town State Zip Code 508-385-5891 - S1147 Telephone Number License Number B. Certification I certify that: l 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 cn 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 10/24/2018 rector'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. ' Y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `. 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 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: PUMPING OF SEPTIC TANK IS RECOMMENDED AS SOLIDS EXCEED 20% OF TANK VOLUME. RECOMMEND REMOVE GARBAGE GRINDER, 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"s ion need to be replaced or repaired. The system, upon completion of the replacement repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for th billowing statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the s is tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration tank failure is imminent. System will pass inspection if the existing tank is replaced with a co plying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection ' it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ (Ex in below): XA t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with bard of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high stati ater level in the distribution box due to broken or obstructed pipe(s)or due to a broken, set d 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 eplaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system re ired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ss inspection if(with approval of the Board of Health): ❑ b ken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explai elow): AA �r_ 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by t Board of Health in order to determine if the system is failing to protect public health, safe r the environment. a. System will pass unless Board of Healt etermines in accordance with 310 CMR 16.303(1)(b)that the system is not functi ing 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 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityfrown 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 m b. System will fail unless the Board of Health (and Public Water Supplier, if ny) determines that the system is functioning in a manner that protects the lic health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)a the SAS is within 100 feet of a surface water supply or tributary to a surface waters ply. ❑ The system has a septic tank and SAS and the SAS is with a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS i ithin 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the S 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 an sis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and t p sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n t r 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 I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 sy em fails. The system owner should contact the Board of Health to determi what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system m t 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 a of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 et of a surface drinking water supply ❑ ❑ the system is with 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is cated in a nitrogen sensitive area (Interim Wellhead Protection Area—IW )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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owners Name information is required for every Centerville MA 02632 10/9/2018 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 aH 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? ❑ ® 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 $of 1reak out? G ® ❑ Were all system components,px uding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityrrown State Zip Code Date of Insp ion D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): aeons r 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 a Title 5 system? ❑ Yes ❑ No Water meter readings, if avail le: Last date of occupancy/us Date Other(describe belo 3. Pumping Records: Source of information: LAST PUMPED IN 2005 PER TOWN RECORD 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of.Massachusetts -Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Nan le information is required for every Centerville MA 02632 10/9/2018 page. -Cityrrown State . Zip Code Date of Inspection D. System Information (cont.)' 4. ,Type of System: x ® Septic tank, distribution box, soil absorption system y« ❑ : 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: TANK AND LEACH PIT INSTALLED IN 1985-33 YEARS. 3 INFILTRATORS ADDED IN 1994 PER INSTALLED IN Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: -2 feet' Material of construction: ❑ cast iron ®40 PVC ❑other(explain): 10 Distance from private water supply well or suction line: • feet Comments(on condition of joints, venting, evidence of leakage, etc.): FLUSH TESTED OK NO L9AK&OR ODORS. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 \ Commonwe4lth of.Massachusetts Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owners Name information is Centerville MA 02632 1 "12018 required for every page. -Cityrrown state . Zip Code ate of Inspection D. System Information (cont.) 2. :Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ganons day(gpd) Basis of design flow(seats/persons/sq.ft., et Grease trap present? ❑ Yes '❑ No Water treatment'unit present? ❑ Yes ❑ No if yes, discharges t . Industrial waste holding tan present? ❑ Yes ❑ No Non-sanitary waste dis arged to the Title 5 system? . ❑ Yes ❑ No Water meter readin if available: \ Last date of occ ancy/use: Date Other(descr a below): 3. Pumping Records: Source of information: LAST PUMPED IN 2005 PER TOWN RECORD Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? i Reason-for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.3 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: APP 8.5 X6X5 1000 G Sludge depth: 8 INCHES Distance from top of sludge to bottom of outlet tee or baffle 26 INCHES Scum thickness 5 INCHES Distance from top of scum to top of outlet tee or baffle 6 INCHES Distance from bottom of scum to bottom of outlet tee or baffle 14 INCHES How were dimensions determined? CORETAKER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): HAS PVC INLET TEE . HAS CONCRETE OUTLET TEE. LIQUID LEVEL IS AT 48"AT OUTLET INVERT. NO EVIDENCE OF LEAKAGE. t5insp.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 222 Pleasant Pines Ave, Centerville, MA `J Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is Centerville MA 02632 10/9/2018 required for every 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 ❑ polyethyle ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or b e Distance from bottom of scum to bottom of tlet tee or baffle Date of last pumping: Date Comments (on pumping recom ndations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outl Invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (I to on site plan): Depth below grade: /A Material of construction: ❑ concrete ❑ metal ❑fiber s ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (lWi 8. Tight or Holding Tank(cont.) Alarm present: ❑ No Alarm level: king order: ❑ Yes ❑ No Date of last pumping: Comments (condition of alarm a *Attach copy of current pumping contract(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 AT INVERTS 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.): DBOX IS IN GOOD CONDITION, ONE PIPE IN AND TWO PIPES OUT. DBOX LIQUID SURFACE IS SCUMMY W NO EVIDENCE OF OVERFLOW. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (Xplan) 10. Pump Chamber(locate on site Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of ps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required If SAS not located, explain why: Type: ® leaching pits number: 1 6'X6'W STONE ® leaching chambers number: INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Citylrown 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.): PIT AND INFILTRATOR WERE EXAMINED W A SEWER CAMERA. LEACH PIT HAD LESS THAN A foot of LIQUID IN IT. STAIN LINE OBSERVED 1.5'ABOVE LIQUID LEVEL. THERE ARE 5 LEACHING ROWS THAT APPEAR CLEAN ABOVE STAIN LINE. THE INFILTRATOR HAD NO LIQUID IN IT. 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 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 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA u Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/201 page. Citylrown State Zip Code Date of pection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydrauli failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c� Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA ' Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 page. Cityrrown 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 VJ C.O., Fi I; Q I I J 1217-Z7 � 5. /q-.0 ?3-31 :9k Y3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1¢of 18 Commonwealth of Massachusetts � Form Title 5 Official Inspection o: p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 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: 16 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) I ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TRANSITED DEPTH TO LAKE : GROUNDWATER IS AT 16.25 BELOW GRADE AT LEACH PIT. GRADE TO LEACH PIT BOTTOM FIGURED AT 115. LAKE WEQUAQUET GUAGE LEVEL IS 33.8'-0.2' BELOW ESTABLISHED HIGH LEVEL. SEPARATION MATH: 16.5-(0.2+11.5)=4.55'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Ave, Centerville, MA Property Address Paula King 222 Pleasant Pines Ave Owner Owner's Name information is required for every Centerville MA 02632 10/9/2018 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 n� No. Fee.12) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes 7' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[pprication for 30iopo at bpotem Construction Permit Application for a Permit to Construct( . )Repair( . )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Q-4- CA SA- Pl At j AA Owner's Name,Address and Tel.No. Assessor's Map/Parcel /�� (/'a ue, r Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No. Sa o.Z Uf ftutevj 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 Nature of Repairs or Alterations(Answer when applicable) b cw A\.� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Aidi of the Environmental Code and not to place the system in operation unti a ertifi- cate of Compliance has been iss Board ealth. G Signed i Date Application Approved by Date Application Disapproved r e following reaso6z XJ - V Permit No. 1 Date Issued <... . . .- No. ��^�� ).._i -----..-------------.----- �— Fee v u ��® THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS � > Digooal 6pgtem Com5trurtion Permit � " �rj�` Permission is hereby granted to Construct( )Repair,(�pgrade( )Abandon( ) System located at a a ; l�••�S /�U� o.:�'�r , and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to e following local provisions or special conditions. comply with Title 5 and the I g p p .� Provided:ConstNctioiy must be completed within three years of the date of this permit. Date: Approved p b f r Y , No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS , 4pprication for Mt000l *p.5tem Construction 3permit Application for a Permit to Construct( )Repair ✓)/Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. a �' }- Q wner's Name,Address and Tel.No. s � eas�� s �.,:..O. Assessor's Map/Parcel /1_ i t(V ll no ^ Er Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � A.•* 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 Septiic. nk Type of S.A.S. «. Description of Soil' r Nature of Repairs or Alterations(Answer when applicable) P \( +. . 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 iit operation until a Certifi- Cate of Compliance has been issued.,by this Board caf ealth../ Signed (' vt UNiva ' Date Application Approved by �� � r� Date Application Disapproved f r e following reasons Permit No. Date Issued 0 THE COMMONWEALTH OF MASSACHUSETTrQD BARNSTABLE, MASSACHUSETTSCertificate of c�Cotn liance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(;� Upgraded( ) Abandoned( )by V at C ra S n�� p n t.S Av C „,l l� has been constructed in accordance with the provisions of Title 5 and the for Disposal System! Construction Permit NJ dated Installer �_, ��: n RtiMnUS T F�rG Designer The issuance of is petmit shall not be construed as a guarantee that the system wild nction as d s}9 ied. Date h, f) Inspector l �n ` T' Commonwealth of Massachusetts K �0- 001-00d--, = Title 5 Official Inspection Form z Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �:a a M 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 �s Property Address Peri Wentworth B ' Owner Owner's Name :_.. information is Y ,Centerville MA 02632 Jul 10 2015 required for every r.�.y page. City/Town State Zip Code Date of Inspection Iti.t Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, # r 0 5 use only the tab 1. Inspector: �' r key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response raa Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 10, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will.perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 •f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. Removal of garbage grinder is recommended, B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. - ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Y 10, 2015 Centerville MA 02632 Jul required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health;safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 222 Pleasant Pines Avenue -Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is required for every Centerville MA 02632 July 10, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow t5ins-3/13 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 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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—IW PA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 9 P Y Y 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information Description: A 3 bedroom system was installed by Arch Construction in 1985. Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 514 gpd Detail: 2013: 181,000 gallons 2014: 194,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is required for every Centerville MA 02632 July 10, 2015 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 9 p ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y 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: Age: 29+ years. A new system was installed at time of dwelling's construction in 1985 (Permit#85- 771 at Health Department). Infiltrator system was added in 1994. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Sewer tine appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank i metal, list to s eta, age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 7 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y 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 I 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y 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 at outlet inverts Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into both leaching facilities. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 , I ge Commonwealth of Massachusetts = Inspection Form Title 5 Official Ins p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ® leaching galleries number: 1 ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into both leach facilities. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I • I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is required for every Centerville MA 02632 July 10, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately LEACH PIT CNtN O 04 •95 1000 GALLON p SEPTIC TANK 2 o/s 1 �9�BL 508 364-0894 (nl_V C9 A OMB V O� QO NOT DRIVEWAY TO THIS SKETCH IS / SCALE BEST VIEWED IN COLOR FORMAT / L 0CA TONS OF SEPTIC COMPONENTS —DISTANCES IN DECIMAL FEET A 8 1 12 27 �p 2 23 38 3 _ 42 42 4 28 40 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 222 Pleasant Pines Avenue -Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15 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: 8/30/1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health- explain: Previous inspection report ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows the bottom of the leach pit to be 2 feet above the bottom of a witnessed test pit in which no groundwater was encountered. Previous inspection report indicates groundwater is 15 feet below the surface. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 p , Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 222 Pleasant Pines Avenue-Assessor's Map 234 Parcel 1-2 Property Address Peri Wentworth Owner Owner's Name information is Centerville MA 02632 Jul 10 2015 required for every Y page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE — NOT TO SCALE i PRECAST LEACH W PIT 0 BOTTOM OF s LEACHING rn PER DESIGN PLAN LEAOIINO IS ABOVE FIION GROUNDWATER O N NO GROUNDWATER ENCOUNTERED t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS l° // EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION de— TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 222 Pleasant Pines Avenue Centerville, MA 02632 ��1 Owner's Name: Jerry Epstein Owner's Address: Date of Inspection: August 7. 2007 l p O;L Name of Inspector: (Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: 6508).862-9400 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 N e Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: August 8, 2007 The system inspector shall subs i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 r V , Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 222 Pleasant Pines Avenue Centerville MA. Owner: _Jerry Epstein Date of Inspection: August 7 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not detenmined (Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: _ Jerry Epstein Date of Inspection: August 7. 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detenmine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliforn 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 h ' ' 1 OFFICIAL.INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: _ Jerry Epstein Date of Inspection: August 7, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. ✓ Any portion.of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool.or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is.within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead.Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question.in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: _Jerry Epstein Date of Inspection: August 7, 2007 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping infonnation was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? ✓ — Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: —Jerry Epstein Date of Inspection: August 7, 2007 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 Number of current residents: I Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No . Seasonal use(yes or no): No Water meter readings, if available(last 2 yearn usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: _ Currently occupied 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): Pumping Records GENERAL INFORMATION Source of information: Pumped in Aug. 2005 Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Infiltrators were added in 1994-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 222 Pleasant Pines Avenue. Centerville MA Owner: Jerry Evstein Date of Inspection: August 7 2007 BUILDING SEWER(locate on site plan) Depth below grader Materials.of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Commnents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: To trade Material of construction: ✓ concrete _metal _fiberglass polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):certificate) (attach a copy of Dimensions: 1000 awl. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: /" 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: 101, How were dimensions detennined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Cement tees were present. The li uid level was even with the outlet invert. There did not appear to be any signs of leakage. 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: 222 Pleasant Pines Avenue Centerville MA Owner: _Jerry Epstein Date of Inspection: _August 7 2007 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: Alann in working order(yes or no): Date of last pumping: Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was normal. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Corrunents (note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: _ Jerry Enstein Date of Inspection: August 7 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 ate_ ✓ leaching chambers,number: 3=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.): The leach it was dr . The scum line was ypyr.oxhnatgy1 Yup from the bottom. The infiltrators were dry, There did not yapear to be an Si ns of allure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 222 Pleasant Pines Avenue Centerville MA . Owner: Jerry Epstein Date of Inspection: August 7. 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. (BA B C3 � � a �. 43 SS y 3 3 q;- 10 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VO LUNTARY AS SESSMENTS SMENTSSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 222 Pleasant Pines Avenue Centerville MA Owner: Jerry Epstein Date of Inspection: _August 7 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water IS+1- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable to o ra hic and water contours maips. the mays were showing apj2roxhnately 1 S'+/_ at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 3 Town of Barnstable OF tHE Tp� Regulatory Services MAB Thomas F. Geiler, Director BAR9�A ' AM 16.59. •0� Public Health Division !FD MIA A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Trr#ifiratr of Complianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .... t, 6 ....-.. ------ � �'.f------------- ----- ---------------------------------------------------------------.............................................. at .., . .. . 4r SFIti 1 .. ...1 G - - - - has been installed in accordance with the provisions of TITLE -of e State Eqn. ironmental Code s described in It application for Disposal Works Construction Permit No. -..._.. .........._..-..._._...... .. dated .� _..�_..............__.._ SHALL NOT B C NSTRMS A GUA'RA TEE THAT THE THE ISSUANCE OF THIS CERTIFICATE SYSTEM WILL FUNCTION SATISFACTORY. � /' DATE.... .. - -.. Inspector - - - ----------------------------------------- ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE.-.2. Difivn Tel orkii (go urtion Wrmit Permission is hereby granted (n�?l ��------ � �r to Construct ( ) r Repairer ) Individual Sewage Disposal Syst�in at No � - jrdam)------..'-ti,E--- ---- V --------- .... ---------•---------------- •-----....... .� - r. street as shown on the application for Disposal Works Construction eer ti at No. ______._ ated..3.-=�jrL.`.?��..._ ") ---1 � ._ Ali �.� % . - �......... / _ _....:_ -in --- ,/ v-G Board of`H�ealth� DATE-----... FORM 36508 HOBBS♦!WARREN.INC.,PUBLISHERS 100, q-OQ a3k- gorn#taWo Coneervat wn Department ---- F�m c.............................. T < Ct 1-1 HE COMMONWEALTH OF MASSACHUSETTSA { OO +� BOARD OF HEALTH ON, 1 TOWN OF BARNSTABLE TAP_ Appliration for Ditj-Voottl Works Tatititrnrtion 11Prbtit Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at, ------------- Location-Address or Lot No. Owner Add ess a ......... •-••_ rn ................................. -vt I/............. Insta!er Address ype of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-----------------------------------------___Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures .----------•-------------------•--......--------------._.__..--------------------------- ---••-----....-------------•--.-----•--••-.-.----•---------._ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 0� Septic Tank—Liquid capacity.�6aq__-gallons Length---------------- Width---------------- Diameter---------------- Depth................ Disposal Trench—No. ..t_______________ Width_,_................. Total Length.................... Total leaching area------_.............sq. ft. 3 Seepage Pit No...../.........:... Diameter.._61._.-----__-__ Depth below inlet... Total leaching area...:..............sq. ft. Z Other Distribution box (.k�) Dosing tank ( ) aPercolation Test Results Performed by----•---------------------------••-----------------•---------•----------- Date----------------------••--•••-••------ Test Pit No. 1................minutes per inch Depth of Test Pit-----............... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 ...................................••------.._..--•--._._._...----..__.------•••••••---------•---•--......................................................... 0 Description of Soil........................................................................................................................................................................ x --------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------•------- ------ x •---•-----•--------------------------------------------------------------------------------------------------------- - -•------- --------- --------- fiU Nature of Repairs 2rlterati — nswe when a licable... ................._-__._.,�zu �.l �6 0-1J.____._________.___...__. -------------------------------------------------------------------------------••---•-•-•--•---. Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. XX Signed -- -....g.- ..... _1*---- --- / Dace Application Approved B PP PP y ..... ......... .. . ---- - -- ------ --------------------------- ................................ .. Date Application Disapproved for the following rea .............._.....-__.................................. ....-. // Q , ?"3 Permit No. - ---------- --- IssuedC-,%l-L� e ... ............................ i .............................. THE COMMONWEALTH OF MASSACHUSETTS f]� aQ +�� BOARD OF HEALTH ��_ TOWN OF BARNSTABLE Appliration for Di-nVoottl Work,i Ton,itrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ()() an Individual Sewage Disposal System at r .......................�. .eS2/` .. N U. ...........- '� =a •••...---•......._.....----••-•-•••......---•••...-•••-.•... Location.Address or Lot No: Owner Address te t?-c S-------------------------------- (, �� �Ql�i�w . ��•k v. st ..I�istaler Address of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms---3----------------------- -- -----Expansion Attic ( ) Garbage Grinder ( ) a~ Other—Type of Building ---------------------------- No. of ersons------.__.--_--_-_-_-------- Showers — yP " g p ( ) Cafeteria ( ) dOther fixtures ........................................................................--------------- ---------•---•••••••• ----••••-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity qo--gallons Length---------------- Width--------_-.---- Diameter--...........--. Depth................ x Disposal Trench—No. .�................ Width.,.................. Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No-----�..------------ Diameter---6--.--. -_.--- Depth below inlet... Total leaching area..................sq. ft. Z Other Distribution box (.�o) Dosing tank ( ) aPercolation Test Results Performed by----------------------------- ............................................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ............................... --••---•-•••-•--•••••••••.....-••••••••••••......••----••-•-._...............------------------------------------....__...... 0 Description of Soil....................................................................................................................................................................... W U .....•••-••-•...-•••••---•••••••••--•-••--•••••.......•••••-----•--••-•••-••-••••••••••-•••••......--••----•----••-•••-•••••••--•--------••••••-••••-----••---••••••-•••--•-•••-••-•••--•••••••-•......•. x •---••---------------- ----------------------------------------------------------•------------------------------ -...----------------------------------- -- -------------------------------- U Nature of Repairs or 41terati2� Answer when ap licable---f -------.---.---tnt J___________•_•_•__-_____- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signedrns: e � .......... . ........ f... 9.�......:...... ........... Dace A lication A roved B ��/l�/ --- ..... �PP PP Y ......::... :..._ � �� -............. .............._Dare.....--'-'--......Application Disapproved for the following rea ................_..............-..................------------------.._------ ....................................................... .....�...../l.. -----------............----------------------------------- ------- ---------------- ............ ...........--::--------------... ....... Permit No. �� Issued ------- - -.y.................. Dace TOVV OF B `P.NS'i ABLE a� 1 LCytA X)N !O V,7..LAGE C �(U� ASSESSOR'S MAP & a OT_ INSTALLER'S NAME&PHONE NO. 2 SEPTIC TANK CAPACITYe- LEACHING FACILITY: (type) (size) _ NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: tJ� COMPLIANCE DATE: Gl' 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 Ftbanished by Fl R a � ►a a� 3 � a3 38 y 3 ya tia y a8 yu ,L0C,AT ON SEWAGE PERMIT NO. `''may' AvE F 27 7 VILLAGE Nib v/ Ile INST,�LLER'S NAME & ADDRESS 7 7.s- /3.6� B U I L D E R OR OWNER DATE PERMIT ISSUED / � z� DATE COMPLIANCE ISSUED- /IC2 ke7, - OF BA.RNSTABLE l.1tATION ��" A PInLf SEWAGE # VILLAGE CaATtfVAL ASSESSO 'S MAP & LOT 001-0 INSTALLER'S NAME&PHONE NO 2 Gw_ SEPTIC TANK CAPACITY O 1 1 LEACHING FACILITY: (type) PST'+ l� rj�Ta1 (size) 5-x a0/ NO.OF BEDROOMS 3 BUILDER OR OWNER 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 leaclul facility) Feet Furnished by ��SPGy"�'00 ��� _A i A Q i ► a 9L a OL 3 3 ya qX y yo TOWN OF BARNSTABLE to LQ::A 1 OON `\"p`� / !v 1AJr 1461L SEWAGE # 941" 93 -co OCR VILLAGE CP Jry,U/�/E ASSESSOR'S MAP 6T LOT INSTALLER'S NAME & PHONE NO.0 ©m Rum au SEPTIC TANK CAPACITY 100C) Q A� LEACHING FACILITY:(type) 3��/S`s� A��Zs (size) 9' NO. OF BEDROOMS PR#TE WELL OR PUBLIC WATER BUILDER OR OWNER Z222it (d'd�'Q SSl�li�/✓ e� DATE PERMIT ISSUED: -9 DATE COMPLIANCE ISSUED; ' VARIANCE GRANTED: Yes No �jy L PT ,ll��Aoas o 004�_ Fps.................•---......._ THE COMMONWEALTH OF MASSACHUSETTS BOAR.........®- OF HEALTH o cc ki..............oF........ Appliration for Dhipaan1 Warks Tomitrurtion thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal 11Sys em at: _..._ ..... ---•---•-----•-------------------- - Location-Address or .......- - ............................................. Owner Address a ---•------•••.. .............. --------------- ------- . - $4 Installer Address L1 Type of Building Size Lot.2ik_AAAI.....Sq...... Zo ., Dwelling—No. of Bedrooms... ....................................Expansion Attic (�� Garbage Grinder PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ......................... . w Design Flow........'................. .L� ®._gallons per person der day. Total daily flow-----as.o........................ lonj.1 WSeptic Tank—Liquid capaci �._ Ions Length.` 'G..... Width.4.-10... Diameter-------_ Depth-.---._: 4 x Disposal Trench—No..................... Width.... Total Length.................... Total leaching area......_.... sq. ft. Seepage Pit No..............�...l. .. Diameter.....1.Q_........ Depth below inlet.... Total leaching area..2-G�...sq. ft. z Other Distribution box l��s Dosin ank ( Percolation Test Results Performed byj..L `�. -•-1- C. ........ Date... �S! ----.._ a ° � ,.a Test Pit No. 1.L-._-_-minutes per inch Depth of Test Pit-___CZ......... Depth to ground water-�I CaI_ s uu_M�Zw 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descri tion of Soil----_ ------ .......1z o 4v�1_ v 2 w --- ��p ----- U Nature of Repairs or Alterations—Answer when applicable;___- _Q6tt. _ -" ' --_•, - �L. ---- 'S `7. -----------------------------•-----•--------•-----------....------------•---•-----....-----.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI:E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed the b and of health. Signed----... ..... • -- ........... ................................ Application Approved BY •-----...... ` 'a`�.. �'� ° /`... � '�Date S Date Application Disapproved for the following reasons--------------------------------------------------------•--------------------------------------------..........-- ..--••--•-•---------------•-••-••---------•--•------••-•----...........---•--------•-•---•...--•--•••---------•-•••-------••----•---•.......•---•----••--•--••--•--••--•---•---------------•---------_.. Date Permit No........ � _-`T ............. Issued............................................... Date 7" No......... J---..... h� Fizs........................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH . o•.. . r..9- , .. ................oF...............:.-:� !.s...�-� --••--......__._....... Appiiration for Diapaii al Vorkg Tonstrnrtion .erntit ' Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal .. ......k ►� S..........................A................... .. S 'C� ---- ------ j O SAA .. Address 1 ••---_ `\ n C w Owner Address a ---•..............._.........----•••••••-----._...----•-•.....--•--•-•••-••••••••-•••---••••--•-- Installer Address 1 UType of Building Size Lot.. .`.._....... ....Sq. fe t Dwelling—No. of Bedrooms.....J .....................................Expansion Attic ( Garbage Grinder ( O a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures Design Flow........5`.....•........ _i.;.:...�_ allons per person per dpy. Total daily f�gw.__..3�-'__ gal W .•-••--. --•_.. lons, 1 WSeptic Tank—Liquid capacity_._........_ lions Length..`('---. Width.° .�10_ Diameter____"'""'_ Depth_`"-•.."�- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--_--_ _... sq. ft. Other Distribution box -` , inlet....�............ Total leaching area--S �_.sq. ft. Seepage Pit No.............. __ � Z ( Djameter.- DosipgtankDepthbJelow\ Percolation Test Results t Performed by.........................................- ! -11 "- � / W .................................. Date.-- /4-� Test Pit No. l.. ....minutes per inch Depth of Test Pit.....!.=....... Depth to ground water_.0 L_ wv--VGZy) fZ4 Test Pit No. 2................minutes per inch .Depth of Test Pit.................... Depth to ground water........................ ----_-------.---•-------•- Descrption of Soil..... --....1%. ---••---•--••..............•--- ... .................................. Y_ + � ►'4' v A.o.-a C> c' �? A V ...............................- --.......__ ,V�'�.-- x -------------------------------------------------------- ----•••-•------------•-..... U Nature of Repairs or Alterations—An s when applica�__-�?C�2� •-•' --_- tU i?�•�z- :IS Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is*d by,the b iard oof�health. Signed....... ..�"�`-2% ... 'a......... .....----Dat ................. ....... f Application Approved By---•------•-•--••---••......-- ,'..r•--------•-•-------------------------•--.....----.......••. ------...... .....L?� " ;...-- Date Application Disapproved for the following reasons:................. .................................•-•--••-----•-••••••-••----------•--.•-•-•---•--•...---•...--------..:•--••---•------------•-------•--•--•-•••-•-•-••-•--•-••--•••-•--••-----•---••---•••-----••-.----- Date PermitNo............. ate-- .............................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..................................................,..................................................... C.rrtifiratr .of Toutph anrr THIS S OCCERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....-----•---------r-------------r--77-``- --------------------•--•--•--------•----• --�j,-----��--- -------------- ...... .--------- .---------------.---- -•------------------ -----.-------------- / Q '' Installer L., e T� at.---....---•--••-----••-•-••--L . ....-• ---- - fit..- , ►� has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ :" _" ......... dated--------- : - ............ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI LUI FUNCTION SATISFACTORY. -- DATE............. ...'.�l/ ..... Inspector._... ----••-•------••-----•-----•-------•-----------------.......-•••••......... t Y THE COMMONWEALTH OF MASSACHUSETTS t, BOARD OF HEALTH t ..........................................OF...............••••..•---.................•.••--••••-••......................•• ... No......................... FEE....:: ...... ._ ElisposFal Works w1.vmtrnrtinn rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Re a' an ndiv ual Sewa Disposal System at No.•-••••. �.....1` ..... -- '--- k�.--•-- --N.--- 'v`� �R� ... Street as shown on the application for Disposal Works Construction Permit No.............. 'Vated.... � ` --`s............. -------------------• + i Board of Health I.............................. �� � �t �,. DATE---....... 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