Loading...
HomeMy WebLinkAbout0029 PRISCILLA STREET - Health 29 i rIs illa 'street Centerville 7A-= 246 - 059 � S M EAe No.24IMIAR UPC 12M emead.com • Made In USA I ONO-O Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 29 Priscilla Street r� Property Address PM;1 Michael Christo Owner Owner's Name / "— Information is required for every Centerville MA 02632 12-8-17 page. City/Town State Zip Code Date of Inspection °do' 1„:11, J-1h 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 A. General Information �� �a� filling out forms `\ Illtirlrr�s/,, on the computer, ` ,4 OF use only the tab ��� �t , 1. Inspector: � ••'' • ' 9 . key to move your � cursor•do not m c James D.Searts DAMES key the return Name of Inspector coY Company Na Enterprises s�;•, o o :4*� ap Company Name 'q�f'•., T �� 163 Commercial Street ���'�� 6 1 N...P���N"' Company Address Us Mashpee _ MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 6 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-8-17 le0ecloes 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.5116 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 of 17 �0qtj6 Z abed xeJ dH 6 6:£Z L 62 01, Da4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments. The system is a 1500 Gal. Poly Tank D Box and four chamber's. 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): 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 abed xeJ dH WE L60Z 06 DaG Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street lu-- Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms 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 ❑ NO(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.doo-rev.6115 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t, abed xed dH W£Z L 1,0Z 06 �EC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla Street Properly Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. City1rown 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 is less than 6" below invert or available volume is less than Y2 day flow� F C/�;,N 15ins.doe•rev.6/16 Title 5 Official Inspection Pear:Subsurface Sewage Disposal System•Page 4 of 17 g a5ed xeJ dH WEE L 60Z 06 D@0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. City/Town state Zip Code Date of Inspection B. Certification (cost.) 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 16,000 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. i5ins.doc-rev.6f16 Tide 5 Official Inspection Form:Subsurface Sewage oiaposal system•page 5 of 17 9 a5ed iced dH WEZ L XF 06 Oa0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. City/Town Slate Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® were any of the system components pumped out In the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage:disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 tSSns.doc•rev.6/16 Title 5 official InspectiM form:Subsurface Sewage Disposal Systerr•Page 6 of 17 L a5ed xej dH UEE L I.OZ 06 Oa4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street Property Address 'Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Poly Tank D Box and four chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015-124,OOOGal g ( y g (gpd))' 2016-17,OOOGal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15,203): Gallons per day(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: 15ina.doc-rev.6116 Title 5 Official Inspedim Form:Subsurface Sewage Disposal System•Page 7 of 17 9 a5ed xed dH Z V£Z L 1,0Z 06 Dai[l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page, Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 DE approval. ❑ Other(describe): t&ns.doc-rev.6116 ride 5 official Inspection Form:Subsurface Sewage Disposal System-Page a of 17 6 a5ed xed dH Z 6:£Z L XZ 01, Oaa Commonwealth of Massachusetts al Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 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: 2001 Permit*2001 -703. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints; venting, evidence of leakage,etc.): wing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: e01 et 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: 1500 Gal. Poly Sludge depth: 2" t5lm.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 0 6 a5ed xeJ dH U£Z L 60Z 01, Da0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. CityrTown 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 NA 1r Scum thickness Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Asbuilt-Plan -Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc,): Tank at working level. Tank and covers at 15"below grade. In and outlet tee's. No sign of over loading. 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 15ins.doc•rev.6.16 T;Ile 5 Official Inspection Form:Subsurtaca Sewage Disposal system Page 10of 17 l abed iced dH £VE L 60Z 0 6 X10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is Centerville MA 02632 12-8-17 required for every _ page. Cilyrrown State Zip Code Date of Inspection D. System Information (cunt.) 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: Dale Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins.doc•rev.W6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Psge 11 of 17 Z 6 abed xed dH U£Z L 60Z 01• 080 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name informationis required wir for for every Centerville MA 02632 12-8-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x1lT-2'below grade. Box is clean and solid w/three lines out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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.doc,rev,606 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System•page 12 of 17 £6 abed Xed dH £V£Z L I,0Z 06 3@0 Commonwealth of Massachusetts Title 5 Official Inspection Form a �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owners Name information is required for every Centerville MA 02632 12-8-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Type: ' ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 two sets of two infiltrators-four chambers total (11'x 37' x10"). Ck D Box and camera out lines. Chambers are clean and dry. No sign of over loading or solid carry over. No sign of holding water. 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 15ins.dw•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 17 6 abed xed dH 'b V£Z L IAZ 06 Da0 4X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t6ins.doo•rev.Oil Tine 5 Offidal Inspection form:Subsurface S6wage Disposal System•Page 14 of 17 5 6 abed YPJ dH t7 LEE L 1,0E 01. Da0 c Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Priscilla Street lug, Property Address Michael Christo Owner Owners Name informatrequired is Centerville MA 02632 12-8-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Cf Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r�Ease LC1K' —I A o s 1 Q-a: -3- 30" t5ins.doc•rev.9116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 9 t abed xeJ dH t,6:£Z L l0Z 0 6 :)aa Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla Street Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 per. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth t high ground water: 1 + 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: 7-20-01 Date ❑ Observed site (abutting prcpertylobservation 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: T.H. on Design Plan 7-20-01 10'+ no G.K. Bottom of chamber's at around 4' below grade. Bottom of chamber's at 6'+ above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6ins.doc•rev.6116 Title 5 Official Inspeclioi Form:Subsurface Sewe;e Disposal System•Page 16 of 17 L 6 abed xed dH tb 6:£Z L V 01, 0-10 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Priscilla Street lug; Property Address Michael Christo Owner Owner's Name information is required for every Centerville MA 02632 12-8-17 page. City/rown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 g abed Xed dH SLU L60Z 01• :20 .t► i�, ., .� 1 � rt �, •v - � ti �� 101 'e Ael,;c/ZM �� v� I h j LI+/ i 1 ■ ow „� I l 1G'o� % ,/�sc 5 i%' ��� � �' /�. 4 ... s. --- —-— �— 71 r} ,.� •�:_ , 1 n V r-. 'I t r S C nr'H �i�,. n..,. /1� ��� �� �; ��� XP I W- i n z -. i n i c i c - .� ..-.,,.non �/ �� / A ►"M r .� I - Commonwealth of Massachusetts a - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ /4r 4 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name r�m information is required for every Norwood _ MA 02062 1/8/2015 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 A. General Information filling out forms I //�0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Neighborhood Waste Water Company Name 350 Main St Ile Company Address W.Yarmouth MA 02673 Cityrrown State Zip Code 508-775-2820 S15016 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ,o-- — _—_— -�� � 1/12/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 'Title 5 Official Irnorm: surface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form R� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. CitylTown 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 in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �( Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel _ Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. CityFrown 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 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. 'e ❑ ® 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. t5iris•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��; 29 Priscilla St. Centerville, MA 02636 �...r Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? I ❑ ® 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): 110x3= 330gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Rr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ... � 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: � Source of information: No Records 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 I bi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , ............. 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 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: 14 Years per records on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): 2 Lines into tank. Lines checked with sewer camera and were found to be clean, properly pitched with no sign of root intrusion. Septic Tank (locate on site plan): Depth below grade: 15"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: 1500Gal. Sludge depth: 6-8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 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 Scum thickness 1-2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal poly tank in good condition. PVC tees in place and clean. No risors on tank. Covers 15" below grade. Tank at normal operating level. 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 'Rf — ----'`1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M _T,c•`'' 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: -- — - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - — - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form RI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�4� 29 Priscilla St. Centerville, MA 02636 t....r Property Address Steven Woelfel Owner Owners Name information is required for every Norwood MA 02062 1/8/2015 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): i 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal sign of solids carryover. Cover of box is 23" below grade. No sign of overloading or hydraulic failure. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): 4- HI Cap H-20 Infiltrators with stone in a 11'x37' trench formation. Units were found dry at time of inspection. Soil is clean with no sign of overloading or hydraulic failure. 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 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is Norwood MA 02062 1/8/2015 required for every — page. City/Town State Zip Code Date of Inspection r_ D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 7 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is Norwood MA 02062 1/8/2015 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 ( Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form JCJ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^ 4 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately ,Sins•3/13 Title 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 29 Priscilla St. Centerville, MA 02636 �...r Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10' 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: 11/27/2001 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: Engineer letter and certified as-built on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Priscilla St. Centerville, MA 02636 Property Address Steven Woelfel Owner Owner's Name information is required for every Norwood MA 02062 1/8/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 P110JECT UES'CRIPTION: ``=. 7-1 C �5%� ~�-s 'QVI� 7- 'i Aa ;?P.O F� Igsr FC (40, CC Fl��Ir c:Li1S.5 AO '20,01 y& 40. © 'YH 2611 FH 32.3• C yx ixo F I v ox F I N1. } Z /7Zl- C Al= =.vim/GT- 4 T'c� vd✓�S Td.,✓ h rr Q r/ 9 7,07 No.78 u �r it CCu.T QL .s6 It D/1.r7- ,OX 1AJ. 91,37 tr rr ri a vT 9G•2.� �,c�T- « i► 9S13 cy� ; Member ASCU aTA 2 FOR., CRAIG R. SHORT, P.E. P.O.BOX 1044 011AIG t LOCUS: z CJ FZ/S4144A ST d SOUTH DENNIS,MA 02660 Professional Civil Engineer-Soil Evaluator (�, civil` TOWN: aoq*;Z'U_T 1'A 4_!z i1-1�9•� Licensed Construction Supervisor-Septic Inspector o. 27�b8v Septic•Site•Piers--Structures•House Designs �a ;c` DATE. r/,/Z 7,/� v l I,E It S� c Office:(508)398-8311 Fax:(508)398-3063 Q J SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) 7Date of Delivery item 4 if Restricted Delivery is desired. ■.Print your name and address on the reverse so that we can return the card to you. C. Signature ■ Attach this card to the back of the mailpiece, X ' ❑Agent or on the front if space permits. Addressee D. Is delivery addre different fr ite r Yes 1. Article Addressed to: If YES,enter de ivery address below: ❑ No 3. SS ice Type LWCertified Mail ❑ Express Mail ❑Registered ❑ Return Receipt for Merchandise JI ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number(Copy from service label) PS Form 3811,July 1999 Domestic Return Receipt a 102595.004-0952 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS `` Permit No. G-10 I' • Sender: Please print your name, address, and ZIP+4 in this box • Board of Health � Town of Bartftbi!o P.O.Box 534 `!;J_nnts,Massadu aft 02W1 �Ii I -,; . �;� i411!!!!1llli�llilltllt�lllltili Ali llll �,� � , �� �! !fit f 1�1 i Ili: ....-....".^.�.-�...r.w-,.r...^-.--�-.�..ra-.-:�..+_-.r.�...t ,r-.,.f�„-''^^...,.n--.......'�',��"�+,•rw.r"'�c*'rr..�1.+f'„.. �,.-.,n„Wiz•-,.v-`�"r'r....•+7....+!*.....-...ntiT�wrr.,.-�i`Lw.la.-,.^+'y,...� . TOWN -OF BARNSTABLE B `-W Ordinance or Regulation WARNING NOTICE Name of Offer.der/ManagerS;(, V AJN./ 1)2CRR MOP-0,"' , Address of Offender j� Z-A 21"k6Tr�'y� MV/MB Reg.# Village/State/Zip ri AI�( /, I . 1 9 o Business Name _+� am/�m on 19 200 ,. Business Address '�` ! � Signature of E K fozcing Officer Village/State/Zip t / Location of Offense �, �, � R V kgim f Enforcing DeP t//D-' n t Offensemq ZA C-cwrr-_ Facts � � lJ � / 4ff! This 'will' seive only a 'a warning. At this time. no -I gal action has been taken. It is the goal of Town agencies to achieve, voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in app!/ryo}p`riiate `l/eggal act�iJon by the To fr� r^-� i�,.-..-+.-.-�+_...�,,,_..�....,-..�...-.--.-.r•Y., ..*',n.-r.a,..-.•.�.r-.r.Y'Cw:.r-.:^^'"+.*.tir-'^ -..,..:� -.R.._n,y..,.M4rKu-n«�T.r.,r..,•v-..,.lt.^ .ii..-�. .".,,r'r.-.xv'�.`rf,.�:.��,ti.rw.^-t.- rt.. , t TOWN OF' BARNSTABLE 4 -w 2005, Ordinance or Regulation a WARNING NOTICE 4 yam, wR Name of Offender/Manager. OPdob Address of Offender 4Pro"t' - 2 MV/MB Reg..# Village/State/Zip f I Business Name aa/ on 20 it Business AddressAli i Signature _ofnforcing Officer . Village/State/Zip Location of Offense „ 9 µ w P f 'Enforcing P De t/iD;Vvis`i n� A Offense FactsI P! + r A #` 14 A HD s This Vill' serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the To 1 "" _ COMPLETE •N COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete are I` -item 4 if Restricted Delivery is desired. ent ■ Print your name and address on the reverse X Name) JEFAddress so that we can return the card to you. B. Received by(Printed C. a to of Delivery �J ■ Attach this card to the back of the mailpiece, 2 ea�i � or on the front if space permits. D. Is delivery address different from Rem 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No Curt Stevenson } 15 Muskett Lane 3. Ice Type Walpole,MA 02091 " ertifled Mau ❑Express Mail ❑Registered Wetum Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2 Article Number (rransfer from serv/ce Iabao i i i i7 p D 8 3230 0002 517? t9 9 61, 4 1 to Pu Form 3811,February.2004 Domestic Return Receipt 102595-02-M•1540 i UNITED STAB1w5 ; e;cd�7s:SEE24l,It3E '� � e"s aid gy • Sender: Please print your name, address, and ZIP+4 in this box • - 1 i Town of Barnstable Health Division 200 Main Street "Hyannis,MA 02601 i j Certified Mail#7008 3230 0002 5177 9961 �IKE T Town of Barnstable Regulatory Services a RAMSTABL& 16 MAC Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 February 28, 2011 Curt Stevenson 15 Muskett Lane Walpole, MA 02081 J NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE I1—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5. The property owned by you located at 29 Priscilla Street Centerville, MA was inspected on February 28, 2011 by Timothy O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration of the Town of Barnstable. The following violations of the State Sanitary Code were observed: 410.450 Means of Egress: Observed a room within Southwestern (SW) portion (near breezeway) of this home being used as bedroom without proper second means of egress. You are directed to correct.the violations listed above within twenty four(24) hours of your receipt of this notice by removing all beds from said room and cease and desist from using said room as sleeping quarters. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH 44homas�AMcKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Scott& Lynn Durante, Tenants QAOrder letters\Housing violations\Rental ordinance\29 priscilla street cent TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION - �/' ' Date Time: In Out Owner Tenant C� II/tn11�G� Address Address Complian,pe Remarks or Regulation# Yes VNO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width �j 2-. 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; ( 2 Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) -5 Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here Town of Barnstable P�oF IKE Tati Regulatory Services BARN'-,TABLE. • Thomas F. Geiler,Director Y MAM. 0:59. Public Health Division ArFD MAC s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 15, 2009 Attn: C.O.M.M. Fire Health Inspector Jaime A. Cabot, R.S. conducted a rental inspection in accordance with Chapter 170 of the Town of Barnstable Code. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 29 Priscilla St., Centerville,Assessors Map-Parcel: (246/059) I - Carbon monoxide detectors not provided for all bedrooms. Smoke detector not provided for basement. Jai e A. Cabot, R.S. Health Inspector /0 QAOrder letters\Housing violations\Rental ordinance\\Fire Violations\FIRE TEMPLATE.doc b3a�� o e-ct m � o � o � r 6 r - Imart Saw&money. Live better. qlrJk 2103 OPO 00005117 TEI 16 THO 02262 v 1ALARM 002611176910 17.97 X KE ALARM 001717106672 11 ,T'7 X TIGHTS 0011111710026 43D NN � TIGHTS 001104960697 b.DO N F6 10PXB1KNI 00609434662 8,60 3, N OP JR C00RD 073608024110 DD 0 F8 LEGGING 0020136MI T6 5.00 N °' P4 IRTN HXR 082013604166 6.00 N r6 LEOGINO 08T0 3604164 6.D0 x 1 FS LEGGING 0820�SUB10TAL T1,99 s 'V V TAX 1 6.260 N 1.86 70TAL 73.85 VISA TEND 75.86 ACCOUNT 19544 APPROVAL 9010161 � TRANS -9 9307 6 flANS I 16 6610327T �l Vl VALIDATION -HMC4 PAYMENT SERVICE - B CHANSE DUE 0.00 -e ITEMS SOLD 10 9 1C9 226 9439�706 1630 4976 II�IIIIIIIII�III�1��VI II�II���I�DaI IIIII��IIIII W lant uou to Pau the loweat Price. I Ask about our Prlcs vetch Pollcy, /03 0 ;11 / 9 13 21,62 WCUSTONER COPYMes IN 0 ' r TOWN OF BARNSTABLE BOARD OF HEALTH Aoproved: Ci 11 141-001 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITIATPONeft: Date b�l Time: In � Out Vti 1 Owner o i-A i(A ST5r"/fQ ` Tenant L N Y,0,Z(�V� Z Address 5y-C-1 Address l SG+ LLn 'T Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities A S 1.(,v 1 &10 , 7. Lighting and Electrical Facilities 1\IO Cp b9ef-Tcc-ro ti 8. Ventilation +/� �i p a ip IFU C , N LL- 9. Installation and Maintenance of Facilities Iz(, ov^�-- 10. Curtailment of Service �ZO U �A --r,f-f-p)Z 11. Space and Use I/ TALC.L-A 12. Exits �wloy-Fz g'C�20� ®r► S�MEA,'� 13. Installation and Maintenance of Structural Elements ez"®TAlk 1 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal --j- �--� 16. Sewage Disposal , / e 17.Temporary Housing �A- 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; ►�f+J'C� �- P¢ M I--.. -Tv Removal of Occupants; Demolition �� �QG S"r tc,, Number of Bedrooms Number of Vehicles Allowed (max) / S'V Number of Persons Allowed (rr td� Person(s) Interviewed Inspector z If Public Building such as Store or Hotel/Motel specify here Health Complaints 19-Mar-02 Time: 10:00:00 AM Date: 3/19/1902 Complaint Number: 3321 Referred To: DONNA MIORANDI Taken By: BARBARA SULLIVAN Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: Business Name: �! Number: 29 Street: Pricilla Street \ Village: HYANNIS Assessors Map_Parcel: Complaint Description: Old garbage covered over in back yard, furniture in the front yard. Actions Taken/Results: Investigation Date: Investigation Time: _ V o �v � 1 I /✓ / � OWN OF BARNSTABLE �' LOCATION SEWAGE # ..c!0 1 Z3 VILLAGE f ASSESS & LOT US )u 3 0 INSTALLER'S NAME.&PHONE NO. G SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r� � G�1(size) NO. OF BEDROOMS BUILDER OR OWNER IV PERMITDATE: I Irf I�b COMPLIANCE.DATE: Separation Distance Between the: F ximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet vate Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet rnished by �� 1p `7 � ` �-eSc� 1.r. •NO. " /U. y ,r ; r s . - Fee to 1 } THE COMMONWEALTH OF MASSACHUSETTS r~entered in computer: Yes PUBLIC HEALTH DIVISION -TOW OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migooal *patent Conotructfon Permit Application for a Permit to Construct( )Repair 4 1 Upgrade(Abandon( ' ) ElComplete System ElIndividual Components Location Address or Lot No. ji` Owner's Name,Address and Tel.No. Assessor's Map/Parcel Inst75n l.No. Desi er's Nam ddress and Tel.No. ni C, 16* low Jb,?rAr i:5 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow U� gallons per day. Calculated daily flow 3(, ,0 gallons. Plan Date 'ZO G, Number of sheets / Revision Date Title Size of Septic Tank , . Type of S.A.S. /7 Description of Soil op %�- fR� ^rvlr�G ENGIN T.4F s SAND CE nA A,,._.. - /,('00RQ BALLED Nature o Re °or.Alterati ns(Answer w e a _pli able) PVC p W Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu y 'is Board lth. Signed f` ' Date C' Application Approved by Application Disapproved for a following reasons J!,JSTALLATION AND CERTIFY IN `V tii 1 ' I it SybIEM WAS WMALLED IN r n.-.^,MM AA RAA'"fry. n Permit No. o `—�b� Date Issued 1 f t Fee TOMM'QNaIVEALTH OF MASS ►CFUS S . , ntered in computer: 14 .t'- ;ems Yes PIBUC HEALTH-DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 14 2pprication for. Oigpool *p%tent Cottgtruction Permit t A lication for a Permit to Construct )Repair U rade Abandon ❑Complete S stem ❑Individual Components PP (�� P Pg (,�S , ( ) . P Y; Po a Location Address or Lot No. Zq ('j ,� (L /�C Owner's Name,Address and Tel.No. Mots rf'" OL9pIse n Assessor's Map/Parcel Inst Name,A{ddre s,and�Te'�o.�_r� Deper's NamgwAdd�res's and Tel.No. » P 90 --973p2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building.4- No.of Persons Showers( ) Cafeteria( ) Other Fixtures 22 Design Flow J. gallons per day. Calculated daily flow W gallons. Plan Date 9 O O / Number of sheets / Revision Date Title Size of Septic Tank 06 w Type of S.A.S. /n CC eS Description of Soil 1 r n Nature o Re dirs or Alterations(Answer w etf a plic ble) 1.0AS �� w - V a w ♦. a44 l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t s Board f lth. Signed �� Date Application Approved by Q Si� �.� `C Date Application Disapproved for the following reasons 1. Y • 1 Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTHJY, that�hh O -site Sewa e D' osal j� stem C$. cted Re aired U raded Abandone ( )by at 0 5 a. \ r has been constructed i acc p,rdance with the pMW ' ' s o Title 5VUUJILIO e for Dis Sy e Construction Permit No.. .�1 � ated !C� Installer U4(.e- Designer The issuance o this •ermit shall not be construed as a guarantee that the sy wilt f nction as �es gne Date Inspector A / 6�2_ _ _ No. -------------------------Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ;Digpogar 6pgtem Con!5r)Ab Y gton Vermit Permission is hereby ran onstruct , )Re )Upgrade( radendon( ) � ed System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date ofi is n't. j Date: ( % �� roved A b PP Y i 1 l t. � J11 1 November 17, 2001 29 Pricilla Street Hyannisport,MA Mr. Thomas McKean Director,Barnstable Health Department Barnstable, MA Mr. Mclean, This letter is to certify that the septic system at the above noted property was installed in substantial compliance with the designed plans Sincerely, Thomas arcgllo,P.E. OFsf� � -FHOMAS yG UAaCELLO CIVIL " No.24421 � •sip R�C��E���ti``, NAL �-� — a• 'Sc P 'WB 3 a i3- ,,,�- :. - " t t�� t LOCATIO1� ci q. _SEWAGE # � LADE ASSESS & LOT Us ..INSTALLER'S:NAME.&PHONE N0. SEPTIC TANK CAPACITY LE?iCHING`FACII.ITY: (type) t /llWJ(size)' NO.OF`BEDROOMS BUELDER.OR OWNER PERMITDATE: COMPLIANCE DATE: I ?�' Separation'+DI:farce Between'tlie: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility.. Feet Private Water.Supply We11 and Leaching Facili an wel, :cxist ty: y on site or within 2M feet of leaching facility) Edge,of.Wetland and Leaching Facility(1f any wetlands eusi within 300 feet leaching,Facility) • Furnished by • l v The certificate of compliance for: 29 Pricilla Hyannisport,ma Is NOT valid. It was given in error. The system was inspected by Craig Short and David Stanton on 11/16/2001. The septic tank was NOT level. At the end of the day the system was NOT completed correctly. Craig Short was going on vacation for the week,and could not sign the letter of compliance as he could not view it. Craig was going to have Robin shoot the level of the septic tank when available the week of 11/19/2001. The compliance certificate was given in error at 4:00 pm on Monday, after Danielle called David Stanton and asked if it could be given out,and David gave her permission,because he had a letter stamped and signed by an engineer,as well as the as-built card. The following morning,As David reviewed the letter,it was not by Craig short,or Robin,it was another engineer(Tom Marcello), and therefore is not valid. Robin went to view the site,but it was buried,and therefore did not complete it. Roger is going to have Craig complete the inspection and sign it when he gets back from vacation. ° V l C/J y �� THOMAS R. RUGO Attorney at law 720 Main Street Hyannis, MA 02601 508 775 1171 January 16, 2002 Thomas A. McKean Health Agent Board of Health Town of Barnstable 200 Main Street Hyannis,MA Dear Tom; This office represents Darlene Roberts of Roberts Septic regarding her show cause hearing now scheduled for Wednesday January 23, 2002 at 7 p.m. at Town Hall. Your notice to Ms. Roberts regarding this hearing was dated November 26, 2001 (attached) and it is regarding work performed atc29 Priscilla Street, Hyannisport. As you know,the day after the date of your letter the design engineer signed off on this system finding"substantial compliance with the engineered plans". The certificate of compliance was issued and the home purchase closed. Please inform this office if the show cause hearing pertains to any other work performed in the Town of Barnstable separate from the Priscilla Street job so that the respondent,Darlene Roberts dba Roberts Septic,may be on notice of any other subject jobs that the Board may be inquiring about. Ms. Roberts recently notified me about a concern raised by a customer 7aftermaking,inquiries at the Office of the Board of Health. Allegedly on De31, 2001 a customer of Ms. Roberts,Mr. Robert Magliozzi, requested t address of Ms. Roberts from your Department,while at your offices Mr. Magliozzi was allegedly told by town employees from the department of the Board of Health that Ms..Roberts was"shaky, (that)you made a mistake hiring (Roberts Septic);they are going down, we,are pulling the plug on them, they are skating on thin ice, they don't know what they are doing". Further statements allegedly made include"They are not liked and we are going after them and we don't recommend them". Moreover, other persons in the.industry have reported to Roberts that personnel in the Board of Health have allegedly spoke slightingly about the work performed by Roberts Septic. Obviously this conduct, if true, by staff of the Town of Barnstable, is unacceptable and slanderous and must cease and desist. �a While it is difficult to measure possible damages as a result of this alleged conduct, it is not impossible. Roberts Septic has instructed me to only request, if this is true, that it end immediately.Roberts does not intend to pursue an action regarding this alleged conduct but reserves its right to do so in the future should the Company learn of continued disparaging remarks made from Town employees at their expense. Thank you for your attention to this request. Very truly yours, �V Thomas R. Rugo TRR Enc. Cc: Roberts Septic CRAIG R. SHORT, P. E. 235 Great Western Road P,O. Box 1044 Telephone(508)398-8311 South Dennis, MA 02660 Fax (508)398-3063 PROFESSIONAL CIVIL ENGINEER, SOIL EVALUATOR, SEPTIC INSPECTOR SEPTIC SYSTEM DESIGNS, COASTAL&BUILDING DESIGNS ' TO: Thomas McKean Health Director Barnstable Board of Health 367 Main Street Hyannis,MA 02601 RE: CERTIFICATION OF SUBSURFACE SEWAGE DISPOSAL SYSTEM LOCATION OF SYSTEM: 29 Priscilla Street,Hyannis,MA CLIENT:Mary Olsen c/o Attorney Matt Dupuy PLAN DATE: 08/03/01 last revised 09/20/01 FILE#: 1-888 DATE(S)OF/TYPE OF INSPECTIONS: 11/14/01 Stake out S.A.S.,review work and Inspect ions with Roger Roberts 11/15/01 Inspect septic excavation 11/16/01 Inspect 3 times, supervise corrections and shoot grades 11/20/01 Inspection by R. Wilcox 11/27/01 Inspect& shoot revised Septic Tank Elevations,Draw As-Built NOTE: The Contractor,Roger Roberts,has been informed that the neighbor has expressed concern about the finished grading.The grading is now approximately 12 inches higher at the property line than prior to the start of the Septic Installation. This may cause erosion,as it has not yet been re-vegetated. Additional grading may also be needed to correct this problem. I, Craig R. Short, Civil Engineer, duly licensed as such in the Commonwealth of Massachusetts, do hereby certify that this firm has visually inspected the constructed subsurface sewage disposal system shown on the referenced approved plan, and further certify that the system, as constructed and shown on the attached As-Built, generally conforms within acceptable tolerance to the regulations, as varied, set forth in 310 CMR 15.000 and the,-Town-of44rnstable Board of Health Regulations. �. ORAIG� No, SHORT I IL , d Craig rt;P.E.,Eng °" 2146' 4 Date cc: File 1-888 f�sSt©NAL Client Mary Olsen c/o Attorney M'at'Dupuy. Contractor Roger Roberts Septic i PIIOJECT DESCRIPTION: `r:. 7-1 ..5 jS r�/� ��S ,C4J/E 7- 1" A4 ;Z0.o` )Soc A4, A A G 6,8` 11f•�` Co A p - et.G` 1oD ,20.0f Fl�lF/Z C C ASJ SEA ri� p ©0 co yK 2"` AW 32..3' F Ys Z/.o Fl qS.m 21 � � v � � v Cox D I Ni I � I I � ZI CL YLI ,cov.valz�. Tj l404V.O Q 7 7,07 - - fir SAFPrl G rAar.a% RAJ 94-78 7- 7- A3 cx 37 770,0 13'®r' Member ASCE CRAIG R. SHORT, P.E. OF �Assq roll: wr,g rzy c� c1s 6-Al P.O.BOX 1044 �� apAIG cy d SOUTH DENNIS,MA 02660 SHORT GPn LOCUS: Z° FZIS.C144A 57 CP Professional Civil Engineer*-Soil Evaluator CIVIL. TOWN: zoq;Z.ti.1.STr4:QLe s r?,g -S Licensed Construction Supervisor-Septic Inspector No.27483 ��a aG0 . Septic Site•Piers--Structures' •House PST Designs ,< c��A'.,' DAT1: I//Z 7/c/ P I i.Is it /"8IM BSI Office:(508)398-8311 Fax:(508)398-3063 . —'� 40 j CRAIG R. SHORT, P.E. 235 Great Western Road P.O. Box 1044 Telephone(508)398-8311 South Dennis,MA 02660 Fax (508)398-3063 PROFESSIONAL CIVIL ENGINEER,SOIL EVALUATOR, SEPTIC INSPECTOR SEPTIC SYSTEM DESIGNS,COASTAL&BUILDING DESIGNS November 27,2001 Dave Stanton,Health Inspector Barnstable Health Department 367 Main Street Hyannis,MA 02601 RE: 29 Priscilla Street,HyannispoM MA File#1-888 Dear Dave: As per my conversation with you, I am enclosing the Septic As-Built and Certification Letter for the referenced property. You should have received my faxed copy,as well. We have received payment(cash)from Roger Roberts. This allowed us to release these final inspection reports so that the Certificate of Compliance can be released by the Health Department. We have also sent a copy to Attorney Matt Dupuy,the owner's representative, so that he will have one for their files. Thank you for all of your assistance on this matter. If you have any questions,please give me a call. Sincerely, 1 Craig R. Short,P.E. Enc. Roberts Hearing Tuesday December 18, 2001 Date: Friday 11/16/2001 Location: 29 Priscilla st,:Hyannis port Permit# 2001-703 Problem: The system was not installed correctly -Septic tank was not level -The stone was not up to the correct level, as the fins on the infiltrator were exposed Corrective action: -The engineer, Craig short, had him adjust the infiltrators, so they were level, and shovel in stone to the correct level. The septic tank was supposed to be raised and corrected on Saturday 11/M/2001, and checked again to ensure.it was level by the engineer. 1)11144, Date: Thursday 12/06/2001 Location: 261 Ames way, Centerville Permit# 2001-730 Problem:. -D-box not level Corrective action: -Re-level the d-box. Already had letter from engineer stating it was installed according to plan. BENCHMARK TOP OF FOUNDATION 20 FT. MINIMUM FROM CELLAR _ J DATE OF SOIL TEST SOIL TEST DONE BY ` ELEV. - Gl o, 0 10 FT. MINIMUM10 FT. MINIMUM FROM SLAB OR CRAWL SPACE CLEAN SAND WITNESSED BY <_: '777774. s� s Lo n E3or (ASSUMED) CONCRETE 4' SCHEDULE 40 PVC PIPE LOAM AND SEED OBSERVATION HOLE 1 ELEV.- �L S _ MIN. PITCH 1/8' PER FT OF PERCOLATION RATE G MIN./INCH AT '�-�- CINCHES 1/B TO 1/2' LEGEND: DEPTH HORIZ TEXTURE COLOR MOTT. OTHER .� ------ - -�---- �4 ,�,e. -J, - WASHED STONE VENT EXISTING SPOT ELEVATION OOxO s -� r i�y� � .�i 4' CAST IRON PIPE I `'17.O r►+..✓ � � S 2 NOT REQUIRED EXISTING CONTOUR ----00---- (OR EQUAL) MINIMUM PITCH 1/4' PER FT. 1 CU. FT. OF FINAL CONTOUR FINAL SPOT NATION - I CONCRETE SOIL TEST LOCATION C wed -71 y FLOW LINE —�-- - c - - 3 a► ANCHOR UTILITY POLE -4 Y -- -- - - . 7.; 10' TOWN WATER --W-�W ELEV. _ MIN. 2. • CATCH BASIN — `■j V. - _ _ LEVEL ° �p• � ELEV. � `�4. ':, GAS LINE n So•-,� ��L ELEV. - y`O OO GAS ENV. - `�- 6' SUMP ELEV. - •-3 .,�- CLEAN OUT C �- Z _ - e� DISTRIBUTION ��� C.P. O � z"'f�' El-EV' o �-.i- �A�A�'- 7Y INFILTRATORS MATH U UID OUTLET L B 0 X � 4- STONE IN AN DEPTh TEE (TO BE PLACED ON FIRM BASE) Z TO BE WATER TESTED , /p�� TRENCH FORMATION 4 FEET 14 INCHES � 7 � , S FEET 19 INCHES rj00 GALLON IF MORE THAN ONE OUTLET , 6 FEET 24 INCHES WELL /.f -JWATER ENCOUNTERED AT ELEV. 7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE.) SOIL ABSORPTION 4' ZONE 8 FEET 34 INCHES SEPTIC TANK 3/4' TO 1 1`2' INDEX `Fl8 � G LI4- -' WASHED STONE SYSTEM (SAS) ADJUST o� cati, C >z.Er<) DESIGN CALCULATIONS USGS PROBABLE WATER TABLE ELEV. - NUMBER OF BEDROOMS _- SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / ) ELEV. - T GARBAGE DISPOSAL UNIT O NOT TO SCALE BOTTOM OF TEST HOLE ELEV. m TOTAL ESTIMATED FLOW ( 110 GAL/BR./DAY X BR.) GAL/DAY REQUIRED SEPTIC TANK CAPACITY o GAL ACTUAL SIZE OF SEPTIC TANK 1500 GAL SOIL CLASSIFICATION DESIGN PERCOLATION RATE MIN./IN. EFFLUENT LOADING RATE 7 T GAL/DAY/SF. LEACHING AREA (1; x 37 )4. 94 A ' 2 Sc LEACHING CAPACITY (AREA X RA:7 3 4 C) GAL/"DAY RESERVE LEACHING CAPACITY 1-j14 GAi_ "DAY NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. j TITLE 5 AND THE TOWN OF RULES AND I REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO I i wl'HIN 6' OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WATI, s, 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BL USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING ►REAS. 4. ANY MASONARY UNITS USED TID BRING COVERS TO GRADt SHALL BE MORTARED IN PLACE. 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH X X 'T �_ DEEDED OR ZONING REGULATIONS. OWNER / APPUCANT IS TO 1/)0.00, . -, ncT+cp r.s► e.r1l)►i MMA APPROPRiaTF AUTHORITY. ., _ t.. 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTk :1011 d 7- 30 c IS TO CALL "DIG-SAFE' AT 1-888-344-7233 AT LEAST 72 RS / O S"OO S F � 7. PRIOR TO COMMENCING WORK ON SITE. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELT AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE ANY VARIATION IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. PARCEL IS IN FLOOD ZONE 9. LOT IS SHOWN ON ASSESSORS MAP AS PARCEL EXlST1NG D►1£LLING I 10. EXISTING SEPTICS ARE TO BE PUMPED AND BACKFILLED. ALL UNSUITABLE MATERIAL SHALL St REMOVED FROM UNDER AND FOR A MINIMUM OF s' AROLNAD LFACHINO FAClUTY AND YE REPLACED NTH /p I MATERIAL AS SPECIFIED IN 310 GAR 15.2-04&(3). �: �,j r- -„ ^, 0 1 C S1W�l.E' X / '4A\. OF vql . p s o CRAIG I I Q i R ��• �: MHO T S. _ 1J` a p � .' 1 Y 8 I� CIVIL ` 21 - '3 0 (-_ ( Ito.27483 � FS� ;c4" APPROVED: BOARD OF HEALTH l I `� I !�a'�' q no/oY DATE AGENT DA,v4ffr way I PROPOSED SoE PTIC DESIGN FR P�5'\t PRO ECT LOCATION o'�" 2 i loo.oo' s�V��� [3.4 R Al S TXJ CAL FEN c � Fo 2 "� .5CRAIG R. SHORT PROFESSIONAL ENGINEER P.O. BOX 1044 508- SOUTH DENNIS, MASS Viu�` rzoa� 398-8311 02660 DATE /�.��C/ SCALE --j I REVISED -1 %:c o/o / JOB NO. - LOCATION MAP REVISED [SHEET OF a 01998 CRAIG R, SHORT, P.E.-�