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HomeMy WebLinkAbout0137 RIVERVIEW LANE - Health 137 RIVERVIEW LANE CENTERVILLE A = 228 178 002 V �AECYCfFOC UPC 12534 No. 2-15.L.R Q�sT CONS°�� HASTINGS, MN it I (I C P II I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentsa M 137 Riverview Ln ww Property Address Van Der Wolk s� Owner's Name Centerville MA 02632 5/10/17 , City/Town State Zip Code Date of InspectiW C0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone 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 qM((11 5/10/17 Inspecto 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. 137 Riverview Lane.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 10 .s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ 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 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a 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 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 137 Riverview Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 1 ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 137 Riverview lane-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Citylrown 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? ® El available 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)] 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 f - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 137 Riverview Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.•''F 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Original septic tank per age of the home, new d-box and chambers 2000 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) Inlet and outlet covers raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500g Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? Measured 137 Riverview Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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.): n/a 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): n/a ' 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box 2'6" below grade, no adverse conditions Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 137 Riverview Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 CitylFown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 per file ❑ 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.): Leach chambers were video inspected and are damp at this time, no indication of past fail 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA • 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 137 Riverview Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 137 Riverview Lane.03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln Property Address Van Der Wolk Owner's Name Centerville MA 02632 5/10/17 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: per permit on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: GIS mapping, Home at 30' contour and stream behind home at 8' You must describe how you established the high ground water elevation: see above 137 Riverview Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: I Frank Nunes III I Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone 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 aS ev sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Titles(310 CMR 16.000).The system: C;. (� Passes ❑ Conditionally Passes ❑ Fails r"S Needs Further Evaluation by the Local Approving Authority 3/15/13 Inspe is Signatu 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. UJI ( lW13 137 Riverview Ln•03/08 Title 5 Official Inspection Fo J5u rface Sewage Disposal System•Page 1 of 16 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ 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): 137 Riverview Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection ❑ broken pipe(s)are replaced ❑ obstruction is removed B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: 137 Riverview Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection ❑ 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. B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a 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 137 Riverview Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 City/Town State Zip Code Date of Inspection ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/s day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 137 Riverview Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone it 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. 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. 137 Riverview Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection ❑ ❑ 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 137 Riverview Ln•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 City/Town State Zip Code Date of Inspection Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a D. System Information (cont.) General Information Pumping Records: Source of information: Pumped a couple years ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest 137 Riverview Ln-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Original septic tank. New d-box and leach chambers 12/7/00 per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Covers raised at inlet and outlet ends of tank If tank is metal, list age: years 137 Riverview Ln-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500g Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle '12' Scum thickness trace to 1/2" Distance from top of scum to top of outlet tee or baffle ,211 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle 137 Riverview Ln•03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection 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.): n/a 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): n/a D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a Attach copy of current pumping contract(required). Is copy attached? Yes ❑ No 137 Riverview Ln-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 16 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityfrown State Zip Code Date of Inspection Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box 2'6"below grade and in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number. 3 per as built 137 Riverview Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 City/Town State Zip Code Date of Inspection ❑ 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.): Leach chambers were video inspected and dry at this time, top of chamber 3' below grade, no indication of past backup D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 137 Riverview Ln-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 City/Town State Zip Code Date of Inspection 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.): n/a D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 137 Riverview Ln•03/08 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 Cityrrown State Zip Code Date of Inspection pia C) 6 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: 137 Riverview Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 137 Riverview Ln. Property Address Mullen Owner's Name Barnstable MA 02632 3/15/13 City/Town State Zip Code Date of Inspection ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 160 feet of SAS) ® Checked with local Board of Health-explain: Permitting on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: >12' per BOH Disposal System Construction Permit on record 137 Riverview Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 DATE 1 1 /1 5/05 PROPERTY ADDRESS 137 Riverview Lane ' Centerville MA 02632 On the above date, the septic system at the address above was Inspected. This system consists of the following: -` �. 1- 1500 ga.Rion zept.ic tank. 2.- 1- Dizta.igut ion &ox., 3.- 3-500 gai on ieach.ing chamaeaz Based on Inspection, I certify the following conditions: 4., 7h.iz 1.6 a 7.it ee T.ive Septic 3y,3tem.' 5., Septic zyztem .ins .in paope2 wo.¢k.ing oadez at the /22e.6ent time., SIGNATURE Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 r Centerville. Mass 02632 • t 7R �� Phone: 5.08-775.3338 or 508-775-6412CID V, w JOSEPH P. MACOMBER & SON,: INC. ,q Tanks-Cesspools-Leachfields - Pumped &-Installed Town Sewer Connections P.O. Box 66 Centerville, MA.026.32-0066 775-3338 775-6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NO1 FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ..1 37 Riverview Lane Cen erville MA 02632 Owner's Name: tri .1 1 YaryL_ Sy r 4.. Owner's Address: 'damp ('',nntArvi11 i44 02632 Date of Inspection: 1 1 /1 5/0 S Name of Inspector: (please print) Qgb�e zt ��A 'EraQl Company Name: �, P—Naco gea & .So.n Inc. Mailing Address: PDX 66 Cen eavi e, flazz. 02632 Telephone Number: 5 0 8-7 7 5=3 3 3 8 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 M000). The system: XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' s Inspector's Signature: Date: I l—I5�1)-5 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. 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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _137 Riverview r.an Centerville MA 02632 Owner: William Bower Date of Inspection: 1 1 /1 5/0 5 Inspection Summary: Check A,B,C,D or E/ALWAYS,complete all of Section,I) A. System Passes: YES NO I have not found any information which indicates that any of the failure criteria described in 310 CNM 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Septic system .iz .in Raope2 w02k.ing o&de2 at .the /2aezent time.. B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass".section need to be.replacedi or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. NO The septic tank is metal and ove..r 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: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): . broken pipe(s)are replaced obstruction is removed ND explain- 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 137 Riverview Lane Centerville MA 02632 Owner:. William Bower Date of Inspection: 1 1 1 5 0 5 C. Further Evaluation is Required by the Board of Health: NO 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: no Cesspool or privy is within 50 feet of a surface water no Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Z. 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: n o 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. no The system'has aseptic tank and SAS and the SAS is`within a Zone 1 of a public water supply. no The system has a septic tank and.SAS and:the SAS is within 50 feet of a private water supply well. no 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 vizuai "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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM `- PART A CERTIFICATION(continued) Property Address: 137 Riverview Lane Centerville MA 02632 Owner: William Bower Date of Inspection. 11 15 0 5 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 X clogged SAS or cesspool 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'%.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. _ .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 orprivy 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 wateranalysis, 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 mor6E0f.the above failure-criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner.Apid 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 1.0,000 gpd to 150000 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 137 Riverview Lane Centerville MA 02632 Owner: William Bower Date of Inspection: 11 15 0 5 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 tho 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 X Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,.opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)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 C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 137 Riverview Lane Centerville MA 02632 Owner: William Bower Date of Inspection: 11 15 0 5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .4 Number of bedrooms.(actual): 4. DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms): 4 4 0 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage system(yes or no):no [if yes separate inspection required] Laundry system inspected(yes or no): a o Seasonal use-(yes orno): yes 2004-26, 00.0ga ions g10D=77.•23 Water meter readings,if available(last 2 years usage(gpd)):2 0 0 3_.2 4, 0 0 0 g a.�e o n-6 G/ [�=6 5 7 5 Sump pump(yes or no): no No wate2 �2om aaa05—dune 05 Last date of occupancy: R u gu z t COMMERCIAlAAUSTRIAL Type of establish m ent: N14 Design flow(1`Wd on 310 CMR 15.203): gpd Basis of de.sign''tlow(seats/persons/sgft,etc.):. Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: NIA 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: 5 yea2e Were sewage odors detected when arriving at.the site(yes or no):a oo 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 137 Riverview Lane Centerville MA 02632 Owner: William. Bower Date of Inspection: 11 15 0 5 BUILDING SEWER(locate on site plan) " Depth below grade: 3 0 Materials of construction:_cast iron X 40 PVC_other(explain):. Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ao.intz aR/2ea2 t.iaht , No Peakagv , VPniAd thnnugh haaAa uoat,- SEPTIC TANK;y e,(locate on site plan)' 1500 ga P P o a z Depth below grade: 24" Material of construction:Xconcrete_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: 10' 6"X5 ' 8"X5 ' 8" Sludge depth. rz a c e Distance from top of sludge to bottom of outlet tee,or baffle: tea ce Scum thickness. t t a c e Distance from top of scum to top,of outlet tee or baffle: t a a c e Distance from bottom of scum to bottom of outlet tee or baffle:t/t a c e How were dimensions determined: m e a z u a e d Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): 10umg tank eve 2 . In-Pet 9 out Pet t 7ank 7.6 3zaucza/zazzy zoun . GREASE TRAP:n o(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.): G2eabe t2ag iz not QnpiPnt 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM �1 PART C SYSTEM INFORMATION(continued) Property Address: 1 37 Riverview Lane Centerville MA .02632 Owner: William Bower Date of Inspection: 1 1 /1 5/0 S TIGHT or HOLDING TANK: n o (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.): Tight o2 hoid.ign tankz ate not 12aezent DISTRIBUTION BOX{ e 16 (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 Dox Z-6toMeP boa-6 2 iate&a26., No zotid ca/tay oven olt . eakage .in o out 01 tox., PUMP CHAMBER: n o (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.): Pump cham9e2 not paezent . 8 r - Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 137 Riverview Lane Centerville MA 02632 Owner:. William Bower Date of Inspection: 1 1 /1"5/0 5 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SA$$not located explain why: Located zee page 10 Type leaching pits,number:_ X leaching chambers,number: 3 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.): Loamy to medium .sand. . No Zi nos V 7-P.ia.eu2e o2 /zond.irzg . SolfA nnv a2y. eger-a .c�on 7z noama CESSPOOLS:n o (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: 040 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.): cebh/2ooi4 ate not /?2esent PRIVY: n.o (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.): l.¢.ivy 1-6 not /la.eZent 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT VOR VOLUNTARY ASSESSMENTS SUBSURFA:CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)` Property Address: 137 Riverview Lane Centerville MA 02632 Owner: William Bower Date of Inspection: 11 15 0 5- 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. .. .. .: kj y � i e 1. ail A� 3 1 P , J� r 10 �m Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: . 137 Riverview Lane Centerville MA 02632 Owner: William Bow , Date of Inspection: 11 1 5 0 5 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: •NO Obtained from system design plans on record-If checked,date of design plan reviewed: y e z Observed site(abutting property/observation hole within 150 feet of SAS) ,"Checked with localBoard of Health-explain:a h 6.a i Z I- nexlLd no Checked4ith local excavators,installers-(attach documentation) �AccessedUSGSdatabase=explainA��R:�own.19a2nstagie.,ma. ups You must describe how you established the high ground water elevation: llhed. ; Ca e Cod Commihion Natea 7agiz Codtouah And Pake.ic Uatea Sup��y Gleii head aotect i.o-n aaeah ma Se _ 9995 Watea sehouaceh oQfice cage cod comm.iZzon., cp -of Ground Leaching Pit : sect Groundwater: Feet Below Bottom•of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bottom �y of the leaching pit and the adjusted groundwater table is G feet. CJ 11 y •„„rtiTM.—Isrr.r•Iwrn►�ws,n*•+►+'"^R � AB RNSmART.F. --, 130AR OF 11RALTII 'DOWN OF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CEItTIF1CATW"1 ••r1�-r•:-,: -*++wR*Tr'"'""'""'"�� �^� -TYPR OR PRINT ""RLY_ PROPERTY INSPECTEI? , 137: Ri ' Centerville STREET ADDRESS ve v ASSESSORS MAP, BLWK AND 'PARCEL OWNER'e NAME William Bower PART D CERTIFICAZKQN ' NAME 'OF 'INSPECTOR Ro 8.ea:t 1?a.o.Un i COMPANY NAME l7acom8.ea'"9 Son Inc Box 66 Can#.eay.i IZ (�a ab' 02632 ` COMPANY ADDRESS .._._..�--� Town-or city BtaL� LIP sc:yet COMPANY TELEPHONE ( 508. Y� 7.5 ' 3338 FAX �' 508',1790 f 578 CERTIFICATION. STATEMENT le 1 I certify that, I have personal'ln •resvrtedaishtrclewas.oattrate•�aandYStem at this address and that the it�formatio P omplete as of the time ..a,.f, inspeetion.�• The in. pe4tion was per-to and any recommendations regarding upgrade., .maintena.nce ,• and repair .are• eongis*tent e in th8 proper function' acid maintenance of on with my trainip,9 and experienc •- site sewage disposal systems► ,� ) �hi:��1 Check one: 1 System PASStD The inspection whic.M -I have .-condu(;ted has .,n•vt• lot.nd any information . which indicates that the system' fails to ' adequately. protect .publi'a health or the envlro#invent as de�Pined in .310 CMR. 1fi*30.3•, Any failure criteria Oot evaluated are as stated in the FAI•LUM CRITERIA section o:f this, form. System FAILED* t The inspection w have aon ted 'has •••found that the qys'tem fails to protect the public lieal.th And the env4ronmen•t ' in ao0o'rdance with Title 61 310 CMR 15 . 303, and as • specifically noted on .Pk.T: C - . FAILURE CRITERIA of this inspection .form. �DaU '0�� Inspector Signature' rndcopy of thyis ceHJfi.cat•i'oh must •be provided 'to : the .QWNER•, the BUYERre apPli•.oa.blo ) and thii I3PARD or HEALTH•. ; * If the inspection FAIL-En., the .ownelr* .or 9perator •a'he,ll, . upg-r.*,de'•the system• within o'ne vear of the aa't•e of the i,napecti on, unl.ee a. allowed or required ' `__..t ..., nrnvi.ded in 110 CMR No. Fee$ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for ]Bi9;po9;a1 *pgtem Cott.5truction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 137 Riverview Lane, Centerville Paul Talbot Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D—box and 3 concrete chambers with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t 's B of l Signed t AA6Date Application Approved by e AC Date Application Disapproved for the following reasons Permit No. Date Issued No. .. t Fee — 'f THE COMMONWEALTH OF MASSACHUSETTS Entered in computef:' Yes // (10 1 PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS ¢ ZIpprication for -Migooar 6pgtem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 137 Riverview Lane, Centerville Paul Talbot Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E . Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title t Size of Septic Tank Type of S.A.S. _ t Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and 3 concrete chambers with stone all around. Date last inspected: T Agreement: Y` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system c 4 h 4ccordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t s B d of Signed / ° Ab Date Application Approved by f Date F°Application Disapproved for the following reasons -6z Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Talbot BARNSTABLE, MASSACHUSETTS (tertificate of (tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by yam E. Rnhi ngon Santi a SPrvi c-e at ben constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated I Iq Installer Wm. E. Robinson Sr. Designer The issuance of this permit sh 1 no be construed as a guarantee that the s, sitem will function as esigADate 0 �l Inspector f � f V , v d�_ — S-- ,sue' ------------------------------ No. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Talbot Migpogar *pztem Con0truction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 117 Riverview Lane., Centerville 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:Cons tr ction 0 m st be c npleted within three years of the date of e t Date: Approved by - NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WTMOUT DESIGNED PLANS) I William E. Robinson,5RlerebY ►that the application for diSPoa works consuuction permit signed by me dated lo�'" 6 , concerning the property located at 137 Riverview Lane, Centerville meets all of the following criteria: • The failed system's connected to a residential dwelling only. There are no commercial or business uses associated ith the dwelling. The soil is ed as CLASS I and the percolation rate is less than or equal to 3 minutes per inch. There are n wetlands within 100 feet of the proposed septic system — There are no private wells within 150 feet of the proposed septic system There"• no increase in Dow andlor change in use proposed • The are no variances requested or needed- bottom of the Proposed leaching facility will mt be located less than five feet above the xi mum adjusted groundwater table elevation:[Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following, A) Top of Ground SttrFdce Elevation(using GIS information) B.) G.W.Elevation _ +the MAX High G.W- Adjustment DIFFERENCE BETWEEN A and B SIGNED :x G-z, DATE: [Sketch proposed plan of system on backl. q.heaM folds:rant i_ ., .. r � .. �� �-y�,� � `/ � I f ' - -- TOWN OF BARNSTABLE ' LOCATION % 3 �► ifS 1,/A tw L d SEWAGE # (1 6 VILLAGE _ Z, t G�� > �ju" ASSESSOR'S MAP & LO = INSTALLER'S NAME&PHONE NO. �o� /•�� .r 7 ? %� %° i' 1, SEPTIC TANK CAPACITY /l j LEACHING FACILITY: (type) 3 (size)%Z- --3<_ NO. OF BEDROOMS L BUILDER OR OWNER /d6 J PERMIT DATE:f COMPLIANCE DATE:,/',?-, Separation Distance Between the: Maximum Adjusted Groundwater Table tcy1he Bottom of Leaching Facility Feet Private Water Supply Well and Le ng Facility (If any wells exist on site or within 200 feet of 1 Ching facility) Feet Edge of Wetland and Leachi Facility(If any wetlands exist within 300 feet of lead facility) Feet Furnished by R ,r r3 • I 1 y -