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HomeMy WebLinkAbout0129 RICHARDSON ROAD - Health 129 Richardson Road Centerville A= 210- 167 S M E A p No. H163OR UPC 10259 smead.com • Made in USA A9vYctpo Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 129 Richardson Rd. . Property Address r:;I MUSIVICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 ss 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. Inspector Information �- filling out forms on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert Paolini use the return key: Company Name 67 Tanbark Rd. " Company Address Marstons Mills MA 02648 City/Town State Zip Code few (508)280-9499 S14454 Telephone Number License Number B. Certification i 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 3/25/20 Insp is Sighdture 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. t5in3p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 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: . 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 u 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. CitylTown 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ 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 must be attached to this form. J 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 c Commonwealth of Massachusetts -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owners Name information is required for every Centerville MA 02632 3/25/20 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) t Yes No El ® 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 12 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 Tess 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 t5imp.doc•rev.WM2018 Tkka 6 c4firdal lsMsp dkm Forw subsurface savage Mspa%al sysJtam•Page 5 of 18 c Commonwealth of Massachusetts F Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City(rown 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)] t5insp.doc•rev.7/2 612 01 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310-CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ?� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,NUCHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 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(seatslpersons/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 1f 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 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town 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: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): ' - Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight. No evidence of leakage.System vented through DBox. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. Cityrrown State Zip Code • Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GI. Sludge depth: 4„ Distance from top of sludge to bottom of outlet tee or baffle 46" Scum thickness 2» Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every two years.Inlet and outlet tees in place.No signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. u Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. Cityrrown 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 129 Richardson Rd. u Property Address MUSNICK,NRCHAEL Owner Owner's Name information is required for every Centerville. MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 No 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.): Box is level.Box has three outlet laterals with equal distribution.No signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 129 Richardson Rd. Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 9 Cultec 4's ❑ 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 1 Commonwealth of Massachusetts �o Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSIVICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 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.): Sandy soil.No signs of hydraulic failure. 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.): l t5insp.doc•rev.7/2 612 01 8 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 129 Richardson Rd. Property Address MUSIVICK,MICHAEL Owner Owner's Name information is Centerville MA 02632 3/25/20 required for every ' page. City/Town 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.): t5insp.doc•rev.R26/2018 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 129 Richardson Rd: Property Address MUSNICK,MICHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Stretch 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 ag 3 4-9 �3x9� c Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSTIICK,NUCHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As- Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used USGS observation well data.Used technical bulletin 92-0001 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 129 Richardson Rd. Property Address MUSNICK,NflCHAEL Owner Owner's Name information is required for every Centerville MA 02632 3/25/20 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable P# 11557 57 Department.of Regulatory Services .�,u, , : Public Health Division Date 200 Main Street,Hyannis MA 02601 Date Scheduled A�Llo116 Time 16 Fee Pd. S it Suitability Assessment for Sewage Disposal Performed By: c-&kc Witnessed By:�t GC"K 7'11L2s f/C.J LOCATION& GENERAL INFORMATION Location Address �.Z� q�_ ,� Owner's Name Address N1 C Assessor's Map/Parcel: r-7 �® _ l Engineer's Name \,�' NEW CONSTRUCTION G• REPAIR Telephone# (,s®8 11 ��3 Land Use t'""' 6�I Slopes(9'0) Z `e Surface Stones Aj/A Distances from: Open Water Body 71� ft Possible Wet Area 2 t S ft Drinking Water Well Z-0 ft Drainage Way 7 1CJU It Property lane 5-C-t It Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) s C r� ���G�ct�dis�• � � �s Parent material(geologic) er&CI�� oci f ujaS. Depth to Bedrock jZ i � 1 " Depth to Groundwater Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: a/,2e Depth Observed standing in obs.hole: l L�° In. Depth to soil mottles: A-flAl- in. Depth to weeping from side of bs.hole: f` " / in. Groundwater Adjustment ' G' „- -ft. , Index Well#4=i u9 Reading Date: e- Index Well level Adj.thetor Adj.Groundwater level,, QCe PERCOLATION TEST DatgIZ1.33 Thee Observation Hole# Time at 9" Depth of Perc 25 7 n Time at 6" 1 Start Pre-soak Time @ l®'3�, - '15mte1(9".6") End Pre-soak /o'Y o 2-1 �`l 4a,; C�M,red Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.D.00 DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, rave Y S/(0 _ L� mvv-� DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil'Horizon: Soil Texture Soil-Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. nsi %Gravel) 2 r tO YP- '313 1Q s 5 L 1© y7Z -6/y 3P CI , 1s9� 5'Y 513 2 M—C— Sow'a c10 vt'�( 1 b 1$ DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munselq Mottling (Structure,Stones,Boulders. Consistengy. Gravel) i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones`,Boulders. Consistency, I Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes ___ Within 500 year boundary No Yes Within 100 year flood boundary No?`• Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious.material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tranertise.'an experience described in 310 CMR 15.017. Signature, Date Q:%SEF'1'lC1PERCFORM.130C i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd °C Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16AN page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in ar way. Please see completeness checklist at the end of the form. A. General Information 61# 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 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 FurtheLEyaluation by the Local Approving Authority 6-9-16 4spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd Property Address :. Jill Woodburn Owner--r Owner's Name information is Centerville MA 02632 6-9-16 required:for every page. City/Town State Zip Code Date of Inspection ;. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E'I 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 in good working order with no sign of failure. 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•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Title 5 Official Inspection Forth: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 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to dogged 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. F l . ❑ ® 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 r 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 Trtle 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 M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® . ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: r 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 6-2016 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 M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/town State Zip Code Date of Inspection D. System Information (cont.) w Last date of occupancy/use: Date Other(describe below): General Information . Pumping Records: Source of information: Owner--pumped 9-2015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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 ,M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 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: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"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.): Good condition. E - Septic Tank(locate on site plan): Depth below grade: 8" .feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. M , 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 2° 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of 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 t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 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:p y 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 M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is Centerville MA 02632 6-9-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from field. 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 ass. P P 9 , Y P Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. Infiltrators ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator leach field in good working order with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 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 <m 4 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 10 �r 3 J6 90., I t5ins•3113 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 M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-16 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: 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: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Tdle 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 M 129 Richardson Rd Property Address Jill Woodburn Owner Owner's Name information is required for every Centerville MA 02632 6-9-1.6 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 i ® 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 c So-. -. LOCATION f S�W, GE II� 'TI .I.ER`S rl E&PROM, sErrc Tix C,PA ^r No.bo BF�T3F OaMS_ 3 B�TIIt�ER OIi Oi71rIER PERIL 'TDATE... CoWnTI 1CB'I?AT Sepa mcd I?istance Between'�e Maxi um Adjusted Groundwj'liA0l to the$ottom of 1, ctitn Fat<4ity Feed i 4i8 ji wwr.SupFty ii�ell an dI�act tt;Fa iiity (ff aay'reds exist as sate or.,a►xtin.2CU faet;vf Ieaetiiszg f ) t Edge of Wetland and- ty{If any wetlands exist wtthsn 300 femt o IeacEtitz�f�«lty)` l � Feet Furnished tiy; 3 C-3 - 36 6 4 ,0.3 /T IF C- y- q73' j'-�- 3,) K i c-Adl-dS on �d TOWN OF BARNSTABLE LOCATION S�14c. a�c�.w &D SEWAGE # VILLAGE G°en.�es�,i,���e ASSESSOR'S MAP & LOT-VIO-1019 INSTALLER'S NAME&PHONE NO. h'���'�-r_ r,A- j�o SEPTIC TANK CAPACITY /00V LEACHING FACILITY: (type) �' e 'Tt L ' y s (size) I3 -4 zP)-y NO. OF BEDROOMS I BUILDER OR OWNER PERMITDATE: l' —! COMPLIANCE DATE:/'.23-02 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by S 32 , c - 3 3 C- V l .o Fee c c. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for �Digonl *p5tem Cori.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( y�Abandon( ) ❑Complete System I Individual Components Location Address or Lot No. 17-9 1t..1 C.4KO Sew 1ZA. Owner's Name,Address and Tel.No.30113 Q 01.5"t-3 CCU l UTb Assessor's Map/Parcel 2 I b Installer's Name,Address,and Tel.No. A5 j CY fL7. CCAvA i i signer's Name,Address and Tel.No. Zt ?>i ) bM(eJ� �J 1 S �?© gc"L akq Type of Building: Dwelling No.of Bedrooms Lot Size 15163!S sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3? gallons per day. Calculated daily flow gallons. Plan Date O Number of sheets Z. Revision Date Title Size of Septic Tank Cu/Shr/Z7 /-OZYV Ql Type of S.A.S. Description of Soil SS1;; Nature of Repairs or Alterations(Answer when applicable) i..l?m'LA1Dg 4-SP�,chA i iJ C -A,R_Eoe. 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 provisi of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee issu tfo<Nard of Health. Sig Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued - _ "•No. .t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF�BARNSTABLE., MASSACHUSETTS f j application for Mood d *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(' )Upgrade(v)Abandon( .-) El Complete System Individual Components Location Address or Lot No. 1Z.9 I.{(_uA"S67_ ILD. Owner's Name,Address and Tel.No..Tcqu ) Q UU—T 1 Assessor's Map/Parcel 2{v- \(�� Installer's Name,Address,and Tel.No. PAS i CrfEZ "EXCAv AS esigner's Name,Address and Tel.No. L►ubt N iC1w)� V.l {LS Po 19c.4- IZ,'s Fc rLT703 ora-�� NAN." IZ CN• C2aSSV-- tt.-It-O T-<5y\��'rh:c,.. t:V; Type of Building: Dwelling No.of Bedrooms Lot Size 15,03 2i sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Y Other Fixtures Design Flow 3 gallons per day. Calculated daily flow 13 y gallons. Plan Date Number of sheets Z.. Revision Date /F-6 Title Size of Septic Tank GC/5l)Z, /071U pe of S.A.S. C,-C E-C- Description of Soil S' A Nature of Repairs or Alterations(Answer when applicable) U P� ,Q_A Q'• IS-a�t_V\ I►J C -A."-,0!1 Date last inspected: l Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system " in accordance with the provisi of Title 5 of the Environmental Code and,not to place the system in operation until a Certifi- cate of Compliance has bee issu t ' and of Health. Sig riga, �+-� Date -1(,-O Application Approved by Date /T/ Application Disapproved for the following reasons Permit No. `' Date Issued ---------------------- ------ — — -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( ) Upgraded( ✓) Abandoned( )by 1,-\,hT i rr- at !� IG rt1�S� Q_Q G vAUM ;Z—at,d constructe } c�'°rdance with the provisions of Title 5 and the for Disposal System Construction Permit No / t 3 Installer PrSTO-72Z Designer The issuance of this permit shallInot be co strued as a guarantee that the ystem wit u• tin s designed. Date Inspector No. ��"'� ��='=----'—=--.-----� -----.—Fee ./ l C/ THE COMMONWEALTH OF MASSACHUSETTS �1 b PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS �Digogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(V )Abandon( ) System located at 1Zg R-1GN1ti 0 5tr,`+ IjZO L'�t.►-i' _y `J, 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 inust b compjled within three years of the date of 5i permt. Date: ,1/` Approved b 0 � / PP Y �, Town of Barnstable oFt"E T Regulatory Services ti tiwP �� x Thomas F. Geiler,Director ► BARNSTABLE, K 9�A �0g Public Health Division 1639. TE A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:. 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# Z Assessor's Map\Parcel Designer: Installer: cJ4C1,r e, 6,k(Y':12 Address: v CrzYj_ 14 ,P C r�� Address: 1 �• Del Le mA On I e 7 A.Z5 f71l-e c:a.Ur issued a permit to install a -( ate) (installer) septic system at % GZt`Ch GirG� pn jZ�� based on a design drawn by (address) �� ke✓ MC r� '�- �' �' '-: dated r v (designer) r, I certify that the septic system referenced above was installed substantially.according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strlpout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Re gu t' ns. Plan revision or certified as-built by designer to follow. Stripout (if require ed and the soils were fo nd satisfactory. P��� of'41 o PETER T, McENTEE CIVIL (Installer's Signature) No, 35109 /;.P DOFFSS/0 t m es1 er i ature (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc a LEGEND "quaquet take c� c� 1 t_ ► PROPOSED CONTOUR PROP. 5.A.5. 2`3 FEE PROPOSED SPOT GRADE i 0 ' / / ,° heod NeedleNo 29, — ..; EXISTING CONTOUR x 100,98- EXISTING SPOT GRADE /,,1 1/2 51Y.` �• WD. FRM.`� t`i'i ' p EXISTING WATER SERVICE '°r �V°"g i EXISTING SEPTIC TANK ST. Great Marsh R e s TOP OF TANK, EL.=100.00 / .- i ,`j i'' ;'f r' �� N EXISTING OVERHEAD .WIRES pry"" INV.(OUT)=98.67t LOCUS " - TEST PIT Route 28 EXISTING S.A.S.—approx. S.A.S. LAYOUT ? EXISTING WATER SHUT—OFF TO BE LOCATED, PUMPED & FILLED WITH SAND BENCHMARK LOCUS MAP N.T.S. STRIPOUT SEE NOTE 11 w . .-. . - N48°54'28"W k �o i48.o2' �oo,s� „F, �% GENERAL NOTES: 90 "` ' 1 700.0 ��S Wkz It 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL AF'*' n O+ �� 0 BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 15,038±5i" '` 700,0 oOCAL THE RULES AN D ENVIRONMENTAL EGULATfONS.CODE, TITLE V, AND ANY APPLICABLE 7 '` 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR --krSg TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 10' 24'—— r 6,9 1 } ' ~µ DESIGN ENGINEER. �� µi 4; ANY COhJDITtONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN gJ4�•cJ•-� ~I ENGINEER BEFORE CONSTRUCTION CONTINUES. '1/ _ 'l 20'0 S9 G� G� k 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. �" -- r 1 29 / ; ut W 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF IN 0 — \ /� tJ1 THECONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 1'P-2 1 j, i�� `/ , o� to �/ it 1/2 STY. ,'' ;- 4y �p HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. /WD. FRM ' -' %/ _ W 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. k o I i : ?•o� ?' BENCHMARK rn 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. 3 ' ' TOP OF FOUNDATION yg o TP-i� J i i. / 7 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED EL.=102.17 O TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. (ASSUMED DATUM) 1 . IT SHALL E THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE r g� C 0 5 L B THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING ` II 1 CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). 12. SIZE AND STRUCTURAL INTEGRITY OF EXISTING SEPTIC TANK SHALL BE y�^ EVALUATED AT TIME OF INSTALLATION. IF FOUND TO BE STRUCTURALLY UNSOUND, TO HAVE A CAPACITY OF LESS THAN 1000 GALLONS IT F 4,..,� 9g3� �, I �. -�, ) 1 — ': 4,, O� � ,�� �� SHALL BE REPLACED WITH A NEW 1500 GALLON SEPTIC TANK. R=2734.57 ., PLAN REVISION OF 1/18/07 — REVISE BENCHMARK LOCATION — Iw __._. — ale f ' � ass k �o' j � � �02g9 Or 'F�'''`� �� — °spa �f o�� PETER T. 9 PROPOSED SEPTIC SYSTEM UPGRADE PLAN McENTEE RICHARDSON ROAD U CIVIL N 129 RICHARDSON ROAD, CENTERViLLE, MA o. 35109 Prepared for: John Boutin, 129 Richardson, Rd, Centerville, MA 02632 Engineering by: Surveying by: SCALE DRAWN JOB. NO. E Engineering Works HOOD SURVEY GROUP 1"=20' P.T.M. 256-06 } 12 West Crossfield Road P.O. Box 1724 Forestdale, MA 02644 Nashpee, MA 02645 DATE CHECKED SHEET NO. 1, (508) 477-5313 (508) 539-7799 1/16/07 P.T.M. 1 of 2 t. NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE I SHALL NOT BE < EL.97.9 FOR A DISTANCE OF 15' ON u ALL SIDES OF THE S.A.S. T.O.F. • EL.=102.17� F.G. EL.100.2t F.G. EL.100.2t (Existing) EXISTING F.G. EL.100.8t MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 1 36" MAXIMUM COVER ` RISER/COVER TO WITHIN INSPECTION PORT TO BE PLACED ON END UNIT a. 6' OF FINISH GRADE AND OUTSIDE OF THE EDGE OF PAVEMENT e L = 21' L =7' 6" 4" SCH 40 PVC 4" SCH 40 PVC LLL10" 14" 0 S= 1% (MIN.) a' ® S= 1% (MIN.) 3' TO . . . o . . o . " 48" LIQUID INV.=98.67t INVERT e;•,•,••,,, EXISTING LEVEL t6 ADD GAS (EXISTING) PROPOSED BAFFLE D—BOX INV.=98.15 3 ROWS OF 3—CULTEC C-4 UNITS x 8'/UNI7=24' INV.=98.39 INV.=98.22 SOIL ABSORPTION SYSTEM (PROFILE) t EXISTING 1000 GALLON SEPTIC TANK N.T.S. (SEE NOTE 12 — SHEET 1) SPLASH PAD TO CONSIST OF NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING UNDERLAYMENT OF FILTER FABRIC PIPE INVERTS PRIOR TO CONSTRUCTION, EXTENDING 16" IN FROM START 2) D—BOX SHALL BE SET LEVEL AND TRUE TO OF ROW 6-4" POLYSEAL OUTLETS GRADE ON A MECHANICALLY COMPACTED SIX ESTABLISH VEGETATIVE COVER 21 INCH CRUSHED S70NE BASE, AS SPECIFIED IN CULTEC NO. 410 FILTER FABRIC BACKFILL WITH CLEAN SAND 2" 2° 1-4" POLYSEAL INLETS 310 CMR 15.221(2). 3) INSTALL INLET & OUTLET TEES AS REQUIRED. (NATIVE OR RC SAND) 4 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE „ ) 12" MIN. „ 2 AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. �r ,n O O TOP OF CHAMBER ELEV.=98.57 c� cyi z INV,ELEV.=98.15 — �_� BREAKOUT 7.9 o U SEPTIC SYSTEM PROFILE BOTTOM ELEV.=97.90 — IIIII III I ELEV.—VITA a0 EXISTING SUITABLE 48" (TYPICAL) 6" MATERIAL -�— .. N.T.S. 5' MIN. ABOVE BOTTOM OF f� fl xT Top View Section T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=13.0' N D—BOX ESTIMATED MSHGW EL: 92.9 = USE 3 ROWS OF 3 CULTEC C-4 FIELD DRAIN UNITS WITH 6" SEPARATION BETWEEN EACH ROW & NO STONE SOIL ABSORPTION SYSTEM (SECTION) CULTEC CONTACTOR FIELD DRAIN C-4 SOIL LOG DESIGN CRITERIA MODEL FD C-4 R STARTER 4" DIA. INSPECTION PORT o � o o a o 0 0 o DATE: DECEMBER 29, 2006 (REF. # 11,557) NUMBER OF BEDROOMS: 3 BEDROOM SMALL RIB LARGE RIB SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: PETER McENTEE PE, CSE WITNESS: ;DON DESMARAIS — HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 G.P.D. �_ TP-2 Depth DESIGN FLOW: 330 G.P.D. MODEL FD C-4 E MIDDLE/END n n Elev. TP=1 De th Elev. GARBAGE GRINDER: NO SMALL RIB LARGE RIB 48 98.9 A 0" 99.2 A 0° n o SANDY LOAM SANDY LOAM EXISTING SEPTIC TANK: 1000 GALLON 98 5 10YR 3/3 5" 98.8 10YR 3/3 5„ LEACHING AREA REQUIRED: (330) = 445.9 S.F. B 8 .74 12" SANDY LOAM SANDY LOAM USE 3 ROWS OF 3 CULTEC C-4 UNITS WITH NO STONE 96.9 YR 5 8 10 24" 96.7 10YR 5 8 e c1 c1 30" FOR AN S.A.S. HAVING THE DIMENSIONS: 13.0' x 24.0'. 8.5' SILT LOAM SILT LOAM BOTTOM AREA: (GENERAL USE APPROVAL FOR 6.7 SF/LF OF C-4 UNIT) 4" DIA. 8 0' 5Y 5/3 5Y 5/3 3 UNITS x8.0'/UNIT = 24.0 FT 3" 94.9 48" 95,2 48"Ct C1 3 ROWS x 24.0' x 6.7 SF/LF = 482.4 SF �5" 8L5- 58" DESIGN FLOW PROVIDED: 0.74(482.4 S.F.) = 357.0 G.P.D. "WALL 0 0 0 0 0 0 0 0 0 M—C SAND PERCM—C SAND RIB LARGE RI 10%GR VEL 70" 10%GR VEL PROPOSED SEPTIC SYSTEM UPGRADE PLAN 92.9 ADJ. G.W. 92.9 ADJ. G.W.= 129 RICHARDSON ROAD, CENTERVILLE, MA CULTEC CONTACTOR FIELD DRAIN C-4 CHAMBER STORAGE = 1 692 CF/FT 88.4 STC. c.w._ 126" 88•4 STG. G.W._ 130" Prepared for: John Boutin, 129 Richardson, Rd, Centerville, MA 02632 ALL CONTACTOR FIELD DRAIN C-4HD HEAVY DUTY UNITS ARE MARKED WITH A COLOR STRIPE FORMED INTO THE PART ALONG THE LENGTH OF THE CHAMBER. 87.9 132" 87.7 138" TM PERC ,'RATE <2 MIN/IN. ("C2" HORIZON Engineering by: Surveying by: SCALE DRAWN JOB. N0, PH: (203) 775-4416 ) EngineeringWorks HOOD SURVEY GROUP N.T.S. P.T.M. 256-06 PH: (800) 4—CULTEC CULTEC Contactor®and Recharger® STANDING'G.W. EL.=126" (TIP-1), 130" (TP-2) 12 West Crossfield Road P.O. Box 1724 FX: (203) 775-1462 Plastic Septic and Stormwater Chambers INDEX WELL ,A1 W-247, WATER LEVEL=23.4 (DEC 06) Forestdole, MA 02644 Nashpee, MA 02645 DATE CHECKED SHEET NO. www.cultec.com CULTEC ADJUSTMENT = 4.5' (ZONE D) (508) 477-5313 (508) 539-7799 1/1 6/07 P.T.M. 2 of 2 {