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Home My WebLink About0051 RIVERVIEW LANE - Health 51 lei v ervi e-w L ane Centerville A=223 — 1/6-- 001 oCYCIfp UPC 12534 N0.2� 15 R , NA81'INOa.NN TOWN OF BARNSTABLE �► LOCATION ` , '� �� +- Ill- --SEWAGE # VII,IXGE 9 \ I� ASSESSOR'S MAP & LO��-IX-061 INSTALLER'S NAME&PHONE NO. yy SEPTIC TANK CAPACITY JCJ0 0 LEACHING FACILITY: (type) Q l�— (size) y� NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) ---�, �n Feet Furnished by AP �K c r� Oo Ac, 41D It 60 '� t Y LOCATION ti, , : SEWAG_ E PERMIT NO. VILLAGE, INSTALLER'S NAME i A00RESS' SUILDER OR OWN-ER 0A T E P ER'MIT ISSUED, DATE COM-PLIANCE ISSUED- is t 20, �D 41 Yq, S T%Z C v E o U O O ca N E) n N N N Q POOL TABLE ROOM UNFINISHED STORAGE a zs •I O a wvui 00m 0 z m G�G ¢00QW Do EXISTING Do Q z a v � W N W UNFINISHED j BEDROOM °C STORAGE ---------------------------------- NOTE GUT ms`SLAB ADOV B'%MATCH EYMLNG GONCRE E o§ NEW EGRESS B POUR NEW a CONC WALL WALL WYI—W CONT. WINDOW WRH 2fYf W FOOTING OONG.FO NG X ta'AW'x GARAGE ABOVE z 0 a 0 z w QE 0 PROPOSED WALK-OUT BASEMENT o Q _w J _J W cc] N cc W W a ?r 0 EE z w EL �v scAle v.�.ru� DAM B/02/16 OMWN By PAB PEVIGgNS: ' DMWWG NUMBED PYRgHi BPB DEBgNB M,S A2 1711 , �� E O U O O ��T11 V CJ/AJ\ .N — I C a d ID'-3 N a G't' �_______________ WIC py�r° KITCHEN + s ® ® a MASTER c7 FAMILY SUITE rz ROOM Q o�= BATH SHELF ¢y Q J Z a0' 11 W In 0aG 10 -0 0 U f W REMOVE EXISTING O a W N WA LS T z 0 Tn STD DIT BM z-0' LU 7 Ir DINING B h ID'S ROOM BEDROOM NOTE:VEPIFY STAIR � DIMENSIONIN FlEID 4 M.BATH FOLDING IRON BOnRD GARAGE z ---------------------------------------------- 0 a 0 z LU LU z T FLOOR PROPOSED FIRS 6 Z m O J 0 3w Q LU J J LU c O cr LULU LU a ¢z O LU a nU sulE va•-r-0� E 5AW16 —ay PAB REVSpNS: DMwiNG MISER Al DOPlRpJrt SPBDESISNS-s E O U O O co V N N Q _N N N Q KITCHEN z LIVING ROOM ® ® BEDROOM a ol® ® :7) '� Z 5§ Ez Qr°Di J w U) o � !D � �Z � N f1J Q OU d w u0i a z� � W o 9 W cr DINING ROOM BEDROOM BEDROOM GARAGE z O a z ui EXISTING FIRST FLOOR o r_ J d O � W Q J 0 J W Q> ts-0• Cr 0 >W IL p ¢Z W 0- nU SDALE 1H'�t'd 5M2/16 DMWNe PAB BEv SgNs: DMWING NUMBED COMBiGHl SPB OESIGUB 20t5 EX I I Commonwealth of MassachusettsI = Title 5 Official Inspection Form f a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster " Owner Owner's Name r=, information is Centerville .d MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection ta, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �) !- on the computer, 0/ lX use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Rapid Response raa Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State. Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Z4 - July 10, 2015 Inspector's ZSignature 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 'Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 _ p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,.if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *`This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is required for every Centerville MA 02632 July 10, 2015 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203,(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information Description: 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 14 gpd Detail: 2013:7,000 gallons 2014:3,000 gallons Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Y Centerville MA 02632 Jul 10 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Owner has called for maintenance pump. 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: Age unknown—system is assumed to have been installed at time of dwelling's construction in 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6-1000 gallon Sludge depth: 15 in t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 19 in Scum thickness trace Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is required at this time-Owner called for service at time of inspection. Maintenance pumping is recommended every 2-4 years with year round occupation.Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 - J i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA '02632 Jul 10, 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No adverse conditions observed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the peastone layer. 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 wM5 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is required for every Centerville MA 02632 July 10, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 51 Riverview Lane-Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10 2015 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 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 L.Oo CA 1 g NSS —OF SEPTIC COMPONENTS —DISTANCES IN DECIMAL FEET EX#SST§nNG A B D /� ELUNG 1 23.5 25 2 25 27 3 28 30 B 4 46 25 A I 1000 GALLON SEPTIC TANK NOT Q 2 TO SCALE j LEACH 0 PIT � OAS, T94e."Ipw Z (� Q 6O Jpo : \ a cr RgVERSME LANE - -lam •• �lJ THIS SKETCH Is 508 364-0894 BEST VIEWED IN COLOR FORMAT t5ins•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 °M 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul 10, 2015 required for every y page. City/Town State' Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ 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: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts _ Title 5 Off i,cial Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 'y 51 Riverview Lane -Assessor's Map 228 Parcel 176-1 Property Address Dawn M. Foster Owner Owner's Name information is Centerville MA 02632 Jul required for every Y 10, 2015 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file GEOHYDROLOGICAL PROFILE - NOT TO SCALE ` I PRECAST LEACH PIT w 04 BOTTOM OF LEACHING PIT LEACH/NO IS ABOVE HIGH OAOUNDWATEA GROUNDWATER ELEVATION PER GIS MAPS 15ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17. No... . .�.7 1 Fss ................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH \4 U = ............oF...� sr- �,. Applirattoo for R-4poiial Works Toutitru.rttoo Urrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat:.......... , ...............................------------------------. .......... ---- '1... ..�s. '`........ ....._................ Locat* n-Address or Lot No. Ca s�- •----•-. --.----- O ner .^� r Address ' ----------------------------------------- ........Oki °-!••-•.--.. ............b('4[m, --•-----•--•--- = Installer Address Type of Building Size Lot__- feet �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of,persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------------------------------- W Design Flow......... .....................gallons per person per day. Total daily 2w.........3.3.4..................gallons. W. Septic Tank—Liquid capacitV4 allons Length--- _.f_ Width.... .__.._ Diameter................ Depth...__... x Disposal Trench—No. .................... Vidth.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No........ Diameter._,lU_'._: 57.... Depth below inlet.._6.._......_.. Total leaching area_, - sq, ft. Z Other Distribution box ( L�� Dosing tank ( ) , Percolation Test Results Performed by.___ ....C2_ ...................I............. Date..... __ ...... a Test Pit No. I---- minutes per inch Depth of Test Pit---- 'f�_ Depth to ground water......rxt . Test Pit No. 2................minutes per inch Depth of Test Pit_ -`._ Depth to ground water.__o.,L.�.._.. f� O Description of Soil =Q. - ..o.._&.d ...---ram' 0.. 1<� GGLe.��..... Q W ---•------------------------•------•.._..._..------------•-----------.---•-......-----•---•-•••••••-----•••-----•••-••-•--------------•----•--•---••--•--------. ...................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT!L- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance een issu y t rd of ned. -••-- .........-- ----- ----- ....... .......................... .... ... ................... at�.. ApplicationApproved BY -------•----•--•- ............................... / .•13........................... Date APplication Disapproved for a following reasons-........................................---------------------------------------------------•----•-••._.......... -------------------------------------•---••------------------.•...--------....---•-------.....------------•••-•-•••--------------•••----••-•------------•------------•------------------•-----••--•-•--- Date PermitNo......................................................... Issued-....................................................... Date No...��- •1!S� Fps.-.......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ......... .. ..........................OF..............................---....... Appliratioat for Di-gosal Works Toatstruriion ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ _..--••-..__...-•----•--•.....---•...-••••----...--.. ......'•-� ....... Locati Address or Lot No. '"'�. y r ................. - f'7 G" ?:.........«.it 0^ ' Ovyner Address . •- ^,✓__..__. . " r ........................................ .......... `"- .......... Installer Address U Type of Building Size Lot---- = _w''�� :. q, feet Dwelling—No. of Bedrooms_........ ..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( ) Otherfigures .. ---------------------------------•------------------------.........•..._....-••-•-••- W Design Flow..........3. ............................gallons per person per, lay. Total daily flow............. ...................gallons. WSeptic Tank—Liquid capacity/�gQ_gallons Length___.__�_._ Width..... Diameter................ Depth__S_"._._.. x Disposal Trench—No. .................... Width.................... Total Length.......... _ Total leaching area...••..i..........sq. ft. Seepage Pit No--------/---------- Diameter.....140....... Depth below inlet_______ ________ Total leaching area._•,.$ ....sq. ft. z Other Distribution box ( ) Dosing tank qq ~' Percolation Test Results Performed by..____-__--.� .___.Q --.�_.__..-_-•-•.. Date.........19 1?•1��__ a Test Pit No. 1...G......___minutes per inch Depth of Test Pit-----�Y,__Y._ Depth to ground water---_..l..... ....... fs. Test Pit No. 2................minutes per inch Depth of Test Pit....Ly_ .... Depth to ground water------- - ...... a •---•-•-•-•--•••-------------•--•-••----•••-•-•--••-•••••-•••--••-•-•-•••-•••-••••-•-••••-•--•--•-••........................................................ O Description of Soil........... _=.30 U •••---•----•-•-••--•--•-••••••••••-•••-•••••••-•--••-•-•-•-•-••••-•-•••-•--••-•-••••.............•••••-•••--•--•-•-•-•-••---•-•-••-------------•-•--•-••••••••-••--••-•••-••-•-••••••-•-•---••-•---•-••. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------•-•--•-•-•--•--•---•-•-........._....-•••-_-•-••-••-•---•-••....._•••-•••.....--••-..._•-•••-------••-........••••••-•••••............ ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. �ed.. --••-••-•--•-••-••-•-•-••-••••-•-••-•••-•--•-••.....-•--••...............••--••• -•' -:•�'" �- ��' a---------------- Application ,. A roved B ---......--•.............•--•---------------------------•_..__ ...1;�f PP Y= = � ;' Date Application Disapproved for a following reasons:-----•---------•-----------••-------------------•--------------------------------------........................ ----------------------------•--•...........-•---••••----••••-•••-•-•-•-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ...........Qu!its...............OF........ ......................................... (Irrtifirtar of Toutpliattrr THI S TO CE�jTIFY That Individual Sewage Disposal System constructed (�or Repaired ( ) by49 /J -,.$' . ..................................... �- Installer _l 4 r 1 /' at. / G� 1"t � i �&Y_sc-..�*a.. h,�.------....ca �� ... --- has been installed in accordance with the provisions of TIpTLE of The State Sanitary Co . as e,cribed in the- application for Disposal Works Construction Permit No._G!__ __�__1'_X ............ dated_-- .. .__Y�. THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................D/? 16-------------------------- Inspector.....�`--= .............................................................. THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD/ OF HEALTH ............./P..*s,,...............OF..---•(� -- ..... ..... .ti---............................. No......................... FEE...3.: . Disposal Workii To trrud- ttFantit Permission is hereby granted--.-----._ f1N_._.._.__./ ,__----to ---.--. to Construct (�or Repair ( ) an Individual Sewage Dl Syst at No... ....... T Street /` • as shown on the application for Disposal Works Construction Permit No.___.___��—__/._(_�_.__ Dated..... t .................................................... Board of Health DATE......................................................�... ..._'� .L FORM 1255 HOBBS & WARREN. INC., PUBLISHERS w� m ,. �,�.«R ,yr:i4�^vi�'"•p"�'M 1 a#.... y{yy,�'. L`r' , � -t- .. f<' .9- '+ "- r'•�-4;�ya`..° :!`tl i�?'a •x,.l .Wx as+• 0 X '�i /-� y., 1 -r .►_ ., // roe i •'�`� 90 u r y 1 x �a %Da'o FvrveE sod rurr 2 y i :[ �i��.f�.!%f.Lr1•UP TEST' � - .._. .._ - L�`?"-ice- N I — ,LAw— .. o. ale• - - _ lt,�• t. 1�TE' v. --.v.4G �,e.4oEs O F N By.CA/r/1' T �E O,G�TE.eM RICHARD r JAMES RICHARD ? O'HEARN -+JAMES 'i v V Na. 27171 O'HEARN LEGEND Me.694 EXISTING SPOT ELEVATIONS 040 URv� EXISTING CONTOUR--- 0- - -- FINISHED SPOT ELEVATIONS n b FINISHED coNTouR PROPOSED PLOT PLAN APPROVED, BOARD OF HEALTH B,geNSTAB,L•E� (u1ASS. DATE AGENT .�oT.l' 7795-7.9¢o i✓E- /�k/�.V� , R. ✓. OWEARN, INC., RL S, RS 1348 ROUTE 134 EAST DENNIS, MASS. DATE: SCALE • JOB N /o/7A CLIENT:_ ! 4 ' e/. �. . ;� DR. BY�L � •� SHEETS OF %2 -:` •C ',, ✓ � 3-'.i.•Mbar ,,. <`�l/, : '•r�•(. 'i'.S 'h' [ 4 .is- E.. ..,t1.: ,. ,_, ., ar_r. 4L a _ ?• .�•'m. .-tea...°: .- i � ` 'P- .� -..'4J .. '.•�' ..�t � "?.'! ln` ..t � P SOIL TEST INVERT ELEVATIONS NOTES, M DATE°•OF' OIL TESj 9 3 8� INVERT AT BUILDING 9 •o FZ ALL WORKMANSHIP AND MATERIALS WITNESSE1 BY `� INLET SEPTIC TANK 9 7 s FT. SHALL CONFORM TO D.E.Q:E. TITLE: 3 Y PERCOLATION 'RATE « MIN./INCH OUTLET SEPTIC TANK 9 7. 3 FT AND THE TOWN OF B"w5772MUcRULES r INLET DISTRIBUTION BOX 9 7. Z FT AND REGULATIONS FOR SUBSURFACE OBSERVATION HOLE I OBSERVATION HOLE 2 DISPOSAL OF SANITARY SEWAGE ELEVATION = B ELEVATION= 9 o OUTLET DISTRIBUTION BOX 97.0 FIT "` " V�* INLET LEACHING PIT 96. 8 FT. ro>Dsaic .sa Sv�soic BOTTOM LEACHING PIT 20•8 FT. ' -30 • —3O" DESIGN CALCULATIONS NUMBER OF BEDROOMS .. . . . . .. . .. . . . 3 GARBAGE DISPOSAL UNIT... . . .. . . . • • . Non/ { CLFA�! /l7ED CLE'9'v MEn TOTAL ESTIMATED FLOW (LLGAL•/BR./DAY x3" BR.)... -73 U GAL/DAY Fsry. 5 AN A REQUIVD SEPTIC TANK CAPACITY..,.. . . .. . .. . . .. . ... ... ¢9S GAL. ' "ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED.... /oo o GAL. - LEACHING AREA REQUIREMENTS SIDE WALL AREA 2.!5GAL./S.F. BOTTOM AREAL GAL./S.F. ° - /✓o �.c�.9r�n - /Yo w•4r n LEACHING CAPACITY ( BOTTOMf- SIDEWALL )...... ..... . .5 4-9•7 GAL. E RESERVE LEACHING CAPACITY.. . . . . . . . . . . . . . . . . . . . . . . 4!5-�9.7 GAL. ' TOP OF 'F.O.UND. " CLEAN SAND ELE V.=/D/ t /D FT �rJ�N CONCRETE 4 SCH. 40 COVERS PVC PIPE CONCRETE MIN PITCH77, . H OF 1/8 PER. FT. COVER i tK OF 12 MAX. '1 3 2% MIN. PITCH =��t A.�..•. ` , R{CH.ARD RICHARD � . .'; o JAMES ro: DAMES FLOW LINE N 2° LAYER OF 1/8"- Ile, o�rtEAep " Or, E^,N • WASHED STONE 4" CAST IRON o 79Z 3/4= i I/2" 9y��SSE�` �ISTE` PIPE - MIN. PITCH , , T� �_ _ va WASHED STONE I/4�� PER FT. BIOX o o o P . h- o PRECAST LEACHING , p caw v v BASIN OR EQUIV. o Q WWes• v �- d ors 779� f 79.00 v--,-v �000 GAL o W o 6 �T B2 N.9S7 98 MASS.. SEPTIC TANK ¢FT R. J. 0 HEARN, INC., RLS, RS € , ID FT Di.¢ A4 1348 ROUTE 134 ` • EAST DENNIS� MASS:. • i;�•�[ PROFILE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM JOB No. /oil ,4 CLIENT NOT TO SCALE DATE/z /6/9 1 SHEET Z OF . 7 j.. a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 51 RIVERVIEW LN CENTERVILLE �' LV.I- / Owners Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:FO Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.,I=am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). Tle system:. X Passes Conditionally Passes r Needs Further Evaluation by the Local Approving Authority Fails r - -T) - Inspector's Signature: Date: 10/12/05 The system inspector shall submit a copy of this inspection report to the Approving Authori_ (Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving, authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different Conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: at this time system MEETS NUNI IUM PASSING REQUIRNIENTS B. System Conditionally Passes: one or more system components as described in the"Conditional Pase'section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due-to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 51 RIVERVIEW CENTERVII LE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 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 CAM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2.System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone I 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 D.System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. — X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 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. You must indicate either"yes"or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered yes'�n 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 51 RIVERVIEW LN CENTERVILLE Owner: NUTTING Date of Inspection: 10/12/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health — X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X — Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X — Was the site inspected for signs of break out? _ Were all system components,excluding,the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X — Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection. 10/12/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): _ Seasonal use: (yes or no): NO 04-5°I0� Water meter readings,if available(last 2 years usage(gpd)):O� 10CP0 Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gnd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): _ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy —Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be' obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 12" Material of construction: _concrete_metal fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: TRACE 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: 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 LOOKS STRUCTUALLY SOUND AT THIS TIME GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass—polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) .Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): PIT HAS ABOUT 1 FT OF SPACE TO TOP OF INLET PIPE 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. FraN LA 'o A -:Z3'G A ,Z- 21 ° AC ' � � AD - -I G RA -2S aD s" Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LN CENTERVILLE Owner's Name: NUTTING Owner's Address: Date of Inspection: 10/12/05 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: t � Conunonwealth of Massachusetts Executive Office of Enviromnental Affairs IF Dept. of Environmental Protection One winter Street Boston Ma. 02108 'John Gt ad ' D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD 508 564-6813 Governor ARGEO PAUL CELLUCCI f. Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION RECEIVED �® Property Address: 51 RIVERVIEW LANE CENTERVILLE — ` a� Address of Owner: OV 1 199n b", Date of Inspection: 917198 (If different) o Name of Inspector: JOHN GRACI DEWER �,. T0WNOFBARWA I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) r'� HEAtTHOEPT. LE Company Name,Address and Telephone Number: Z CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria defined In Title V — COndItio ally asses code 310 CMR W303.My findings are of how the system is performing at the time of the inspection.My inspection does Needs urt r Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Falls septic system and any of Its components useful life. Inspector's Signature: Date: 918198 U The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoTnpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exiiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 _ Sewage backup or.breakout or high static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. -- The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D) SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revlaed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 D]SYSTEM FAILS(continued) Yes No _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ _ Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 04r27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917199 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g p' Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yea Seasonal use(yes or no): Yesila Water meter readings, if avable:(last two(2)year usage(gpd). nfa Sump Pump(yes or no): No Last date of occupancy: nfa COMMERCIAL/INDUSTRIAL: Type of establishment: nfa Design flow:8 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: nfa Last date of occupancy: nfa OTHER: (Describe) nfa Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:8 gallons Reason for pumping: rva TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(if known)and source information: 1982 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' —other(explain) Material of construction:x concreate_metal_FRP_Polyethylene ) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No ('Yes/No) Dimensions: Le•8"H5'7•'W4'10-' Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:l" Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERYTWO YEARS. GREASE TRAP:_ (locate on site plan) Depth below grade: Na Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n1a Scum thickness:nfa 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:rva Date of last pumpingrit- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na BUILDING SEWER: (Locate on site plan) Depth below grade: 2'6• Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction Iine:rOWN Diameter: nIa_ �,_imments: (conditions of joints,venting,evidence of leakage, etc.) (revlaed 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nfa Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nre Capacity: n1a gallons Design flow: nfa gallons/day Alarm level:_nfa Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) No DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: LIQUID LEVEL wmiBOrrOMOFPIPE Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) D-Box Is structurally sound PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nfa (revised O4l27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 51 RIVERVIEW LANE CENTERVILLE Owner: DEWER Date of Inspection:917198 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits, number: 1000 GALLON LEACH PIT leaching chambers,number:We leaching galleries, number: Na leaching trenches, number,length: Na leaching fields, number, dimensions:Na overflow cesspool, number:nle Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAS NOT HAD MORE THAN 6"IN IT. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: nla Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Ne Dimensions: Na Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 51 RIVERVIEW LANE CENTERVILLE DEWER 917198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) A J -AO AR Page ! o! l0 (revmed 0412719T) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 51 RIVERVIEW LANE CENTERVILLE DEWER W7198 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revioed04127197) Page 10 of 10