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HomeMy WebLinkAbout0120 PRINCE HINCKLEY ROAD - Health 1.20 PRINCE HINYLEY RD. r CENTERVILLE i i C. S. Cape Septic Inspections Title 5 Inspections Alternative System Monitoring g 52 Rivers End Road Teaticket Ma. 02536 508-280-3356 septicinspectormike@aol.com Attached is an amended Title 5 Report. The only correction is on the bedroom design. At the time of the inspection Mike did a walkthrough of the house and there are only 2 bedrooms. We now have a copy of the permit attached showing the original design was for 3 bedrooms. Any questions please contact us. Thank you Michael T Bisienere Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is Centerville MA 02632 03/17/2020 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 425 GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail In 2019-104,000 gallons were used and in 2018-121,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Y� w • THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEAL --......1 o..............OF..... A#p1 rafiun -for 3liopuod Works Tnno#rur#iun Permit Application is hereby"made for a Permit to'Construct ( ) or Repair ( ) an Indivi ual Sewage Disposal Sys.. .. ...».......... ............ .................... _....•---- / ...._ .. I ocat� •Addre 'Pr • No '��r�►� d ..... ry........», »»� ...................».. .......... ........... ner Address ..... .».... ....................... -• .:..— -.............................................. pq Installer Address Type o uilding Size Lot.,f.5� ..Sq. feet �..� Dwelling—No. of Bedrooms........ ..................................Expansion Attic ( ) Gar ge Grinder (/i4P aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .....---•..................................•---..........................--•--...._...---•--•---......................----------••......-•-•-•....... W Design Flow.............4.0.................... per person per day. Total daily flow............................................gallons. i Septic Tank—Liquid capacity....I gallons . Length................ Width................ Diameter................ Depth................ xDisposal Trench—lio..................... Width... ............... Total Length Total leaching area....................sq. ft. 3 Seepage Pit No...... ........... Diameter...... ____._ Depth below inlet......___.. Total eacli . l ing area.:01v...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Resul Performed by..............................••--------------..........---•----..._...._. Date........................................ a M Test Pit No. 1._ -- ---minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2.... .....minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---- ...•----------------------------------------------- 0 Description of Soil.._ ! W im___ _�0__ ... .............. • _-- -• - j Nature of Repairs or Alterations—Answer when applicable................................................................................................ ................................................--•........... `.. ......_..................------..............------.....-•-----••-•--•-------....---....-----•-••-•---•--••-•-•-•-•----•---...._. Agreement: M The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not tithe system in operation until a Certificate of Compliance has bee •s ed by th rd of health. Signed. ....................-----..............--••---•--•_.. . ._Application Approved By..._.. '. ...... » ` • Application Disapproved for the following reasons:...................................�7 Date ..................................................... ................... ....................................................................................................................................................................................................... su �. PermitNo..................................-•-----....---......» Issued.......----................... -• ............... Date THE .COMMONWEALTH OF MASSACHUSETTS j BpARD O HEALTH H_ e .............. .....t!°"",( J ..:OF....:......... ............................................. I. "' "�+, � ' f�lex�rfirtt#�e �• f�uut�rtittnrr THIr T E Y; That the Individual Sewage Disposal System constructed or Repaired r .• ...... . •---- -•-_._ ............ ---•--» ( ) ' r `e.�� -... lee _.x.. ........................ has been installed in accordance:with the provisions of . I e State S, itary Code as described ' the application for Disposal Works,;C9nstruction Permit No.!r dated .. .: ».... ....... TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W»1 FUNCTION SATISFACTORY. >L-- 7�i n A TF ,.,�»e....._ . \ �+t ��t��" .�.�`+.g a tr'-`�• �-`, � t` �yi , rX�.cs �*� ,,,��'� ,""t ¢.,� •. t # y# b _Y+wy. ° t �a.k, .A.'7,t �..lki '°"a'• a i' n'. `f ev.. '_f T "t'� sC"u to AP ii. ,� , ��p yy �l.�ryCy',.r� y 4 L •t 'd' �y .� +.,�Y"y''�� s '� s=# 4':'�, : �'• '+�'t T�T�'�rf *Jvr r:�" `$ 05NftifT �;• 4 a.l r1'3R�, �'7�-• r�n,.k a i ^° g x<' 3. }+ �. .p y 1 ' r „}, •, N map = ,"• r .w .!4 f r.j,l 'at.. .,f(.° r � �d+,. 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QS.g 11AR tom:► 37! .t 1 . yL s a '�►+' � + e ',•' 3 GAL - '.i't� . + ►. �A�0AW.4+,!' { ?1,Q►i..l ' 9»' "t.' 6.` t � #tr i Tt 'i4 � °_ tJ►A t Loli M G WT4 OV :6 Q�'t#+ '4�'n '' �. -r,i- � �Q�7 1 F�•��M�Fi �t�j��ay �{ 4 'f`i�i , :tA'trBs�f� t eA yCTEtZ, 46*74.0 r' ..0f j AA,t �iSTEiJZ�i�iLi.� o �14T�fwf�.; � • i>F?LI.GA:►`!"•r_ MA .'VR�'-+. ... ...:.w}..�.ijir..,Yrw��.ry..::+rF.+t+"G"•'�^"_...�..'........v-�:.laa..•.-.. �.�r—r—rt - ..?��4'tf+-••. t Commonwealth of Massachusetts �O /qj Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd f. i Property Address a ,7 Thomas McCarthy r Owner Owner's Name information is required for every Centerville +� MA 02632 03/17/2020 . page. City/Town State Zip Code Date of Inspection r � Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 61 Nq 9 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return key. Company Name 52 Rivers End Road � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 03/17/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 2 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a leaching pit. At the time of the inspection there were no visible failure criteria. The D-Box was viewed with a camera. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts l� Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Prince Hinckley Rd V Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: • **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis mutt be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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 ik t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �u— 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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)] 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �n = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name • information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2019-104,000 gallons were used and in 2018-121,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name ° information is required for every Centerville MA 02632 03/17/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 29"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 ° Commonwealth of Massachusetts Title 5 Official Inspection Form 'I9 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 20"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: H-10 1000 gallon Sludge depth: 2° Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Note: this home has a filter that requies maintenance. I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is Centerville MA 02632 03/17/2020 required for every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 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 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑-No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. The D-Box was viewed with a camera. 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 R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd U� Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): , o t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately ** As-Built from the BOH attached on next page** a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION /;D o0IFIAlct 11/xk11Y SEWAGE# VILLAGE �' f N`r ASSESSOR'S MAP 4 LOT /�Sp1'c7..ps I*TAS!b C'S NAME G PHONE NO. A & B CAN00 775-6264 SEPTIC.TANK CAPACITY f P c 1415)"fe71,11 LEACHING FACILITY:(type) (size) 140.OF BEDROOMS PRIVATE WELL OR/PUBLIC WATER BUILDER OR OWNER N'S,0,'cTi DATE A�D: /0 'vt DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i IL4 317 i J t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 120 Prince Hinckley Rd Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. City/Town 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: 15 plus feeet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit. o ° 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Prince Hinckley Rd V Property Address Thomas McCarthy Owner Owner's Name information is required for every Centerville MA 02632 03/17/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is required for every Centerville MA 02632 August 15, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, ej I � 1 use only the tab 1. Inspector: ���//// I V key to move your cursor-do not Timothy Reed use the return Name of Inspector key. Company Name . 72 East Main Street Company Address Middleborough MA 02346 City/Town State Zip Code 508-958-2684 SI 198 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 Eva lion by the Local Approving Authority � August 19, 2014 `1 e o s SI re 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. e)lb vl t5ins•3113 Title 5 Official Insp ' n :Subsurface Sewage Disposal System•`Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is older, but has seen minimal use over the last ten years. Recommend that the pit be pumped when the tank is to help prolong the systems operational time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 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 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15 2014 required for every 9 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owners Name information is required for every Centerville MA 02632 August 15, 2014 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•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 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15 2014 required for every g , 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): 425 GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15 2014 required for every g page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 97 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: OccupiedDate 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 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is required for every Centerville MA 02632 August 15, 2014 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: Every 2 years-Last 9/12 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is required for every Centerville MA 02632 August 15, 2014 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: 36 years, 8/1978 Disposal Works permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ P PP Y feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1.5' Depth below grade:P 9 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 8'6"x5'x5' Dimensions: litSludge depth: 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 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every page. Cityrrown 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 35" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? 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.): System should be pumped every 1-3 years depending on useage. Tank should be brought to grade for monitoring and maintenance. Tee/baffle were in place. 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 M 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owners Name information is required for every Centerville MA 02632 August 15, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every 9 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 30" below grade. 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 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owners Name information is Centerville MA 02632 August 15, 2014 required for every g page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cover is 8" below grade, top of pit is 40"below grade and there was 3.5'of effluent in the pit. This is more than one day of useage. Recommend the pit be pumped when the tank is to help prolong the operational period. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is required for every Centerville MA 02632 August 15, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 'p 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every 9 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: RI hand-sketch in the area below ® drawing attached separately A) Y 31' a t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is Centerville MA 02632 August 15, 2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/28/78 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil log on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 120 Prince Hinkley Road Centerville Property Address Tom and Mary McCarthy Owner Owner's Name information is required for every Centerville MA 02632 August 15, 2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 15:22' Frofr):E3f;FJJ5T HEALT!j 1508i90S304 To:15083%4264 p 1/3 L,O C A T 10 Nk-Qn.. SEWAGE PERMIT NO, PILLAGE ant e 117 1!l I N ST A L L E N'S NAME 81 A D D A E S S )"L -1s, MA. I U I L 0 E R opt OW?#jR Alar !7t. ma I Lam .5-16 --qL--ntP-rvll.le.,. MA-PATE A T E PERMIT iSSU E D DAT E C 0 M P L I A N C E ISSUE® HUG-11-2014 1 :'22 Focjm:DiH'.PNST HEPLTH IS087906304 u 41e� k 04�-� CPAL: lam{ I" raG Fr 4, 41 Gr L" oz P, Ll 'Tor 17-ou I CP rp C. L-,AM wv, -,Box �e-nc Wv, 7-A Q K q,e T E tqc %4Z.;Z L: TI A w-J C> `rI.:T VGA CY� :-j(Q a AA E. 1,5. a M A S-;. "OT i k 4 LX> A P:-r L. LOT 1-jw�"5 ALK2`.-1A-201A 15:22 From:8PRNST HEALTH 1.5087906304 To:15089464264 P,2/3 No- 3 7HI7 MMMONWFAI-TH rF MA-%NAr.HtJAF.TTA a BOARS HEA I ........... :, ......................... Appliralinu fnr 04juloal VILitka Tondrudian jOrrutil Application i4 h(e7t-!jy'rn;4'v illr 9 Permit TI,) Ct.mATnlqt ar Rvp;lir Indi a! SCIV3.g(- DiSPIAki -G.- ---------------------------- ................. ................... .................... ........... ........ ................. ............. ...... ...................... .............................. .......... T yl� i/.r. kv Dwelling of .................. AUic f i i";aj-46ge Grinder (Ap 1;7 OkNr-- i'yrw of .......... 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V- .............................. ................. .................. -------------------------------------- I ............ ........................N;I'R'7r ji V.cpait-3 or A;tfr,,riitw;—Alvmt- stern appiii-i!lt-� .................. ..................I--.................................._............I........................ Agierme,ni Tilt, agree, to install the -doredrse-ribed Individual Stnvap Jv,;reln in:w.:.,;)ydarsce.with the pvjvL;iunu oi Anide CI yr the State.Sx,itavy Cotlt- Tbr w:de:-%iFned{artier agrces not to pl k the iyStPTFI it tV. en:ttion utE :L Certificate of Coxiipfiariu has Weq,`alled by thr lyd of 1,.eAth- Signed- ................. ......... cd L ,t X)plimuiotx Visappmved for the toifoa.,ixq ew- c"S:....................................... ........................................................................................................................................ ........... DUO Pamir NO................................................... ........... Tf�Eommo Nwr- -C -ALT14 QF .8QAR0 Oa HEALTH ............. "n'. F ....... (gr�if �t -lit T11 r T9 II'LL Ulf'. rudiviiinvi �ew�-,p niqa,,I;,i S;ste!rn ................... .................... ...... ........ 4- . .................. *--, 4 ----------- bo:!I ia�wfltd Uj the prrr,7�:, -o& iD the ;�Iqdiv;lbnn�cr Li' oUL UCI i0[I PCTMit 5.4......w- dated",I THE WIIANCE OF THIs 4c6,R,TJF!CATk SMALL NOT BE CONSTRUED AS A GUARANYEE THAT THE SYSTEM $FACTORY. F,AiE ........... THZ-.00MMONWFALT)4 OF 4JAS5ACHU51:TTs -4— BOARD HEAL-TH ................... OF ..........................r.................................... Nc.......... ........... prks/C ................. .......... ....... ........ UM r Re!'Mfr.,F '1 'xnPIlt I R DUPW.af *,,,-.yg-V! I I P x,,;-;N:wnwi the application for comavctior"Nu ..!�J........... 61 .......................... rc:,tm 91)dWV %I WAMCN! INC.. P09LiPWFRA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "PN 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information n forms on the '. /'7 c? /9 (7 computer,use 1. Inspector. only the tab key to moreov do not our MICHAEL DEDECKO use the return Name of Inspector I _X key. COMPASS REALTY DEV CORP ` Company Name Q P.O. BOX 2384 C- Company Address MASHPEE MA ' 02649�' _ City/Town State Zip Code:,-' T•1 508-221-5003 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 r., 4/10/07 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. 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is required for CEN_TERVILLE MA_ 02632 _4/10/07_ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 241 pine-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD _ Property Address MARK GREELEY Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 241 pine-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address — MARK GREELEY Owner - —..__-------------- Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 ___ — ----- ------ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - - 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` f 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is required for CENTERVILLE- MA 02632 4/10/07 - __—_-- - _-.. .------_._.-_.--- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 241 pine•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form — —� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is CENTERVILLE MA 02632 4/10/07 required for _ -- --- every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) 241 pine-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts _—W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is CEN_TERVILLE MA 02632 4/10/07 required for --- every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 ------- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 --- Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a_ 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No PRESENT Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: -- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — ---- -- --- — -- Last date of occupancy/use: Date Other(describe): -- - - 241 pine•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 ---_—. -_- - — ----- ---------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: n/a Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: -- --- -- --- —__----— Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: N/A — - ---—Were sewage odors detected when arriving at the site? ❑ Yes ® No 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts _ - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 120 PRINCE HINCKLEY ROAD Property Address MARK GR_EELEY Owner, Owner's Name - - - --- -_------ - ------- information is CENTERVILLE MA 02632 4/10/07 required for --- ---- - — — - --- -.- --- - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 - ------------------.._--- feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): -- ---- Distance from private water supply well or suction line: Town water _ feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight,-yes vented, no sign of leakage. Septic Tank (locate on site plan): 20" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------- ---------------------------------- --------------- Dimensions: 1 000 gallons 2" Sludge depth: — -- ---------..----- Distance from top of sludge to bottom of outlet tee or baffle 32" — -- — - --- 1" Scum thickness - Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured _ 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY _ — — ------ -- Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 -- - — -----_-- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related-to outlet invert, evidence of leakage, etc.): no need to pump tee's intact structurally sound liquid level equal with outlet invert, no leakage_ Grease Trap (locate on site plan): Depth below grade: feet----- ------- ----- -- —.. Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ------- ----- _.----_.__.___.____.-- Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date - ---- -- ___---------.__.-____ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -- - — -- -- -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 241 pine•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 15 c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 12_0_PRINCE HINCKLE_Y_ROAD _ Property Address MARK GREELEY ---------- -------- Owner Owner's Name information is CENTERVILLE MA 02632 4/10/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert equal with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level and distribution is equal yes solid carryover, no signs of_leaka e Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form -- — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY _ Owner Owner's Name information is required for CE_NTERVILLE MA 02632 4/10/07 every page. Ci_ty/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 1 ® leaching pits number: ----- ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ------ El 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.): soil ravel, no sign of hydraulic failure, ponding 1'8", no damp soil, vegetation normal_ 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address MARK GREELEY Owner —.. - -----------------...__--------.... Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 ------ ------ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration ---- Depth-top of liquid to inlet invert ------ ---- Depth of solids layer -----— — — Depth of scum layer Dimensions of cesspool Materials of construction -- -- Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: --------—- Dimensions - ------ — Depth of solids -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 241 pine•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^ a 120 PRINCE HINCKLEY ROAD Property Address _MARK GREELEY Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07 --_— __ --- ------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1 unc>, az r� 241 pine•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 PRINCE HINCKLEY ROAD Property Address . MARK GREELEY Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/07-----_____--- -------------- --------- -- - -- _....—.....-------.__._.....___._.----_---- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 63' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: town of barnstable gis You must describe how you established the high ground water elevation: town of barnstable gis-topo shows ground elevation at 63' 241 pine•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . A a DEPARTMENT OF ENVIRONMENTAL PROTECTION r 350 MAIN STREET i. WEST YARMOUTH;Mk" 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 172 PAR 199 Property Address: 120 PRINCE HINKLEY ROIftl CENTERVILLE,MA 02632 Owner's Name: MARINI,LESLIE Owner's Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 - REGDate of inspection OCTOBER'24,2001 �' Name of Inspector:(please print) ' JAMES D.SEARS Company Name: A&B Canco N 0 V �' 1 Mailing Address: 350 Main Street West Yarmouth,MA 02673 TOWN Or Telephone Number: 508-775-2800 HEAL1 r. . 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority L Inspector's Signature: a- ' _- -3 9- Date: JD 3 -al 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 tot he 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 R. Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 C. Further Evaluation is Required by the Board of Health: N/A _ 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 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance ** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 Systems: N/A To be considered a large system the system must service 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 H 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 is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 Check if the following have been done. You must indicate"yes" or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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(3xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 0 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): N/A Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 1999 15,000/2000 15,000 Sump pump(yes or no) NO Last date of occupancy: 10-10-01 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):' Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 BUILDING SEWER(locate on site plan): X Depth below grade: 181, Materials of construction: Cast iron I X 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 20" Material of construction: X concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 19" How were dimensions determined: TAPE AND PROBE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.OUTLET BAFFLE.TANK AND COVERS 20"BELOW GRADE.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Fomi 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 32"BELOW GRADE.BOX IS CLEAN AND LEVEL.BOX HAS ONE LINE IN, ONE LINE OUT.NO SIGN OF SOLID CARRY OVER OR OVERLOADING SEEN. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: I leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CST PIT.PIT IS 36"BELOW GRADE WITH COVER 4"BELOW GRADE.20"WATER IN PIT. STAIN LINE 4"ABOVE WATER.NO SIGN OF OVERLOADING SEEN IN PIT. WALLS CLEAN. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 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. �!s 0 DO / Title 5 Inspection Form 6/15/2000 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 PRINCE HINKLEY ROAD CENTERVILLE,MA 02632 Owner: MARINI,LESLIE Date of Inspection: OCTOBER 24,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 28 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: Observation site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: G.I.S. BARNSTABLE BOARD OF HEALTH Title 5 Inspection Form 6/15/2000 11 TOWN OF BARNSTABLE OCATION 4-0 JO l /AIC£ /��l�kL£f' SEWAGE # VILLAGE ��� ASSESSOR'S MAP & LOT d la /f IN8TAS=hWS NAME & PHONE NO. A & B CANCO 775-6264 rip A•i r h v,.M.c•{'':E �.1i �{ �.4Y f+' viA �i. ' b a to • V..r SEPTIC TANK;CAEACITY, K ' %wi ,:°' ' .:�� 4..e�.•a.:,.���„.s,`,...Y z•.r Yak., d Q:.. k:..a'f.... ...., ,� ;..'.:. ...... ..�.iY .. .w"`.r.,..A. ..F _.., rs.t LEACHING FACILITY:(type) (sue) NO. OF BEDROOMS PRIVATE WELL OR/PUBLIC WATER BUILDER OR OWNER / °�/ ¢ S •4 /ivbO g'cir-0 DATE D: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 �I ' �L 0 317 0 L,O C A T I01I � SEWAGE PERMIT NO. Tot 126 Prince Hinckley Road 78-382 VILLAGE Centerville, NIA. INSTA LIER'S NAME i ADDRESS Alfred Fuller Went Parngtable Rd. Marstons Mills, MA. 8 U I L D E R OR OWNER Alan R. Small, Inc. Box 536 Centerville, MA. 02632 D A T E PERMIT ISSUED 8/30/78 DAT E COMPLIANCE ISSUED r�� 7 rz r.-� 1. v' .. r t cc� �U 3� �_ �' ����. I y V CY� 1 A ................ " THE COMMONWEALTH OF MASSACHUSETTS t BOARD �FH EALTH ........----OF. a......... ApV irafiott -fur 43WVoiittl Works Tomitrurtton Vrruiit ` pplication is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys em at* too MA......................... r- I- Location•Addre ,or Lo No: -----`-•----------------------- /_1Owner ♦��^yJ^A/ddress _40 Installer Address d Type o Building Size Lot_. . ..Sq. feet Dwelling—No. of Bedrooms------—---------------------------------Expansion Attic ( ) Garbage Grinder (114P pa, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------- W Design Flow.............4a..--________--_-__..gallons per person per day. Total daily flow------------------------------------------..gallons. ,. Septic Tank—Liquid capacity..../. allons Length................ Width................ Diameter---------------- Depth.-.-----__.----- x Disposal Trench— o_ ____________________ Width._. __..___.._.____ Total Length.-________._ Total leaching area--------------------sq. ft. Seepage Pit No......I�............. Diameter...... Depth below inlet_....._..._. Total leaching area-4d.-__-sq. ft. z Other Distribution box ( } Dosing tank ( ) aPercolation Test Resul Performed b Date---------------------------------------- a Test Pit No. 1.. ___/ ._._minutes per inch Depth of Test Pit.................... Depth to ground water....------.-. --.__-. Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._.-.--_-_---------.._ -- ........................ O Description of Soil `•. ). j � . ... ------- ---------------- U ------•--------------q 4 --- a ------------------ ------ UW ............... =--------------------------------------------•--------- -----•-------.-------------------------•----------------------------------------- Nature of Repairs or Alterations—Answer when applicable.-.------------------- ---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: �1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the�State Sanitary Code—The undersigned further agrees not to pl the system in operation until a Certificate of Compliance has been - s ed by th ®ard of health. Signed. .. { ------- � e Application Approved BY-----��------- �--•-- .✓• - -�- Application Disapproved for the following reasons________________________________________________________________________ -•-----------•---.---Date------------- -•...•-•.........................•••--••-•••-----...----------...._..--•---•-----•-•.....--•----•---••••••--•---••••------------•--•-----•------••------------------------•--•-----------------------•- Date Permit No. Issued.•-••s F /--`---��---••-•---- Date - ��� ---------------------------- 76' , No..... -- �....'� '..1................ THE COMMONWEALTH OF MASSACHUSETTS s BOA RD ,OF HEALTH .................O F .... : ApplirFation `for Uiiiposttl Eorkii Toaastrurtion Vrrmit Application is hereby'made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System Yate�: 4,14,4/ /fr Location-Address or Lot,No. . r ......,w� �r .................. ...•i i -1,�- l .. / Owner,,,,-- --- % Address - --- � ! Installer Address ' d Type of Building Size Lot.. {_ __,:. 7 6..Sq. feet Dwelling—No. of Bedrooms_...„07 _----------------------------- Attic ( ) Garbage Grinder ( ) pa.I Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fi. ires ____________________ W Desi n Flow._ _.____.. a ons per person per da Total daily flow..... ____..._ g ---�d�----------- P P P y""•.� Y ---.....................gallons. WSeptic T.,nk Liquid capacity�0�`�11ons Length--------------- 1�'��idth...........-.... Diameter-------.-------- Depth.-.------....... x Disposal Trench—No_ ________ ___________ Width__ ______----_---. Total Length------- .__ Total leaching area.--.-.---__-..___--sq. ft. Seepage Pit NO.._...!. ........ Diameter------ Depth below inlet----- Total leaching area_._____._________scl. ft. z Other Distribution bdx ( ) Dosing tank ( ) aPercolation Test Results Performed by------------- ------------------------------------------------------------ Date---------------------------------------- 1 "Test Pit No. 1_ _-:-._minutes per inch Depth of Test Pit____________________ Depth to ground water........................ f: Test Pit No. 2--------------_.minutes per inch Depth of•,Test Pit_______________-.- Depth to ground water..._.__.-__---..___-_--- • .............. ... . 4... ............ . Descri ption of"Soil v ° .._ _-- , f. •»w x 1 ^f _ g s! _ " ----- ---------- - d z _____________________________A___--_.._.---_---.---_.,.....__-_.__-__________-_.__-__-_----_:_-_________.___-____--___--__.----_---,-----_.,_.-___-.--.--._--______.__--_.--.._._--___--_-__-------.-.__-. U_ Nature of Repairs or Alterations—Answer when applicable--------------------------------------------.--------------------------- ........................ ---------------------------•------------------------------------------------------------- Agreement: The undersigned agrees to -install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State.Sanitary Code The undersigned further agrees not to pla the system in operation until a Certificate of Compliance has been issued by the board of health. l Signed -- --•--------------------------•-• x �c Date ..., Application Approyed By_---. ��"� �:�.. '� M ���� �"*'"�`�"'t"� �� � � � �0 ---------------- Dates �. .>. Application Disapproved for the f ollowing�reasons=-------------------------------------- ----•......._--------•---............................................ -----------------------------•--------------------------------------------------- ---------------------- ,..., -------------------- Date Permit No.................... Issued.----- `-7�......--•...... -•---•••--- d�t--•------•--------•-----------•--• Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH >. .............. ...A-Wet...OF............. .Awgf- ............................................ ¢. wertifirate of (111mplialtu THIS S°" TC!"ft"E Y That the Individual Sewage Disposal System constructed (41"'or Repaired ( ) ......f. ___..h ^'� __..__..... ufi 'by r '� - - ----- - - --- --- ---- . --- ................... ]nst111er AL has been installed in accordance with the provisions of �,Ftic XI of e State Sa."itary Code as described the dated--- 4 application for Disposal Works•"Construction Permit Nfo.> �"_`_____ � ..:" *^____. � , "" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM V�IJ FUNCTION SATISFACTORY. DATE �) Inspector -------------------------•-----•--•---•------ THE ,COMMONWEALTH OF MASSACHUSETTS „,,;: BOARD HEALTH ........................OF................. "" !*�. ......-----.--.............................. i y No.................. --•••- FEE .---- �i��o�ttl �rk,� ��o�traartioat �rraatit Permission is hereby granted__°' ------- � ----- "* r F -fi--•.... .............-----------------•-•-------- .................................. to Construct * . or Repar''( ) aIn�dividual Sew e Disposal Systetm at No..--,-•-.y�# M w9 - ,+� r s A � ' _ y!9� +" _4 a+ s Lt a� a f. + mo d* �..,�......�... ` Street � as shown on the application for Disposal Works Construction Per its No.. �*.....,<4 ated... ' .`�___± _. 8_.- ..-- "'tea. .. #, ; ,Q_,�2-°:............................ Board of Health DATE . ` �'. i FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r Lit t_� f`t mow = t t t> � 3 = 33t� G•p.T�. � tC 'T'Ag-1K. = 3 .r 15C> %. A-9S 6.PD. a •s ejF u5 t t>C>C-n, 6At-- i5�'oSAL. PtT USE t000 Gam. e1TQU At..L ACZA. = 150 s F. 4 ca0 stir. �; t .d + z � �•P D. . ' 'd TOTAL "PESVIo►J = 4 5�►.RLD. ,�� Toro 4- 'b,4.t 1..>f FLDw = 330 6.PP. Tx. 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A 5 B CANOD U5-6264 SEPTIC-TANK:CAPACITY LEACHING FACILITY-(type) (size) IIO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /h/fI l�� F-S aSPscTr� DATE 9"ED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes R£a� a� \_jU•G https:Hitsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=172199&sq=1 1/1