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HomeMy WebLinkAbout0019 ROLLING HITCH ROAD - Health 19 Rolling Hitch Road A= i 92 — 119 ZiM EAd No.2-153LOR UPC 12534 enmd cons • Made In USA r , Commonwealth of Massachusetts Titlee 5Official Inspection Form Susurface Sewage Disposal System Form -Not for Voluntary Assessments r 19 Rolling Hitch Road Ida Property Address �-A Stephen Botello M-4 Owner Owners Name information is as required for every Centerville MA 02632 6-22-18`�' page. Cdyfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information on th f out forms use only the tab I I ��.a �tN Op 1. moo • s key to move your Inspector: 0=1�;• • "•.,qpy cursor-do not ,lames D.Sears =�r JA M ES c use the return _ key, Name of Inspector 8 py Na Enterprises =# c =*, � Company Name 153 Commercial Street iNSPE �`°�� Company Address arm Mashpee MA 02649 Cltylrown State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that 1 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 6-22-18 ;Spelolrs Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. t5lns.doc•rev.61% Milo 5 oNldal Inspection Form:Subsurrsce sewage Disposal System•Page 1 o117 , b _ a5ed XeJ dH ":t,6 YeO2 £Z un( Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F, ry 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name Information Is every . Centerville required for ev MA 02632 page. CftylTown Ei-22-18 State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary', Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are Indicated below. Comments: The system is two block pool's B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for'yes", "no" or"not determined° (Y, N, ND)for the following statements, If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 15ins.doc•rev.6I16 Title 5 Official Inspection Form:Subsurface Se� •vape Disposal System•Pape 2 0117 2 @Bed xed dH 8I,02 £Z unr i • Commonwealth of Massachusetts Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name information Is every Centerville required toreve MA 02632 6-22-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms 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 M303(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 l5ins.doc•rev.6M6 Title$Official Inspection Form:Subsurface Sewage Disposal system•Page 3 0117 8 a5ed Xed dH V�:b 6 8 W2 £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information i e required for every Centerville MA 02632 6-22-18 page, City/town State Zip Cade 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 CEP 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 jVI ❑ ❑ 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 l5ins.doc-rev,06 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 abed xPJ dH bb:b 6 e 60Z £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name . information is Centerville required for every MA 02632 6-22_18 page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s), Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located'in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.611a Title S Official Inspection Form:Subsurface Sev 29e Disposal System.Page 5 of 17 g a5ed XeJ dH bb'-t,6 8 602 £Z unr f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information is required for every Centerville MA 02632 6-22-18 pap. 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 NIA) ® ❑ 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 manholes uncovered, opened, and the interior inspected for the condition of the' I 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 p Y disposal a roper maintenance of subsurface sewage P dis 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)1310 CMR 15,302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 15ins.doc•rev,6116 TIOa 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 9 abed XeJ dH 17�176 8l•OZ £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � .� 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information is required for every Centerville MA 02632 6-22-18 pie. City/Town State Zip Code Date of Inspection D. System Information Description: Two block pool's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes ® No -Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2016-290,00OGal 2017-141,00OGal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: 15ins.doc-rev.6116 THle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 abed XeJ dH 9t7:t,6 8I.OZ £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments moot. 19 RollinQ Hitch Road Property Address Stephen Botello Owner Owners Name information is required for every Centerville MA 02632 6-22-18 page. City/Town State Zip Code Date of Inspection D., System Information (cant.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 850 gallons How was quantity pumped determined? Gage on Pump Truck Reason for pumping: Part of Inspection Type of System: ❑ Septic tank, distribution box, soil absorption system ® aw 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 IIA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval, ❑ Other(describe): 15ins.doc-rev.6116 Title 5 Ofridal Inspection Form:Subsurface Sewag e Disposal System-Page 6 of 17 g a5ed xed dH Sb b 6 8 m2 £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information is required for every Centerville MA 02632 6-22-18 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 40 Years. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Orange Burge Pipeing. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ine.doc rev.6116 Tile 5 Official Inspection Form:Subsurfaoe Sewage Disposal System-Page 9 of 17 6 abed xed dH 9t,:1v6 860E £Z unr Commonwealth of Massachusetts IvyTitle 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name Information is required for every Centerville MA 02632 6-22-18 Cit !Town page. Y State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 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.): 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.doc•rev.6116 Title 5 Offidal Inspection Form:Subsurfaoa Sewage Disposal System-Page 10 of 17 0t a5ed xed dH 9t,:tb6 8l•oZ £Z unr Commonwealth of Massachusetts Title 5 Official Inspection Form k4r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information is required for every Centerville MA 02632 6-22-18 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 t Holding Tank tank must be m g g ( u at time of inspection) locate on site Ian 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 15ins.dor rev.6116 Tige 5 of cial Inspection Fomc Subsurface Sewage Disposal System-Page 11 of 17 6 abed xed dH 9b:b 6 8l,0Z £Z unf c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name information Is required for every Centerville MA 02632 6-22-16 page. cityfrown 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 No Box 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 ❑ 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: l5ins.doc•rev.B/18 Title 5 official Inspection=orm:Subsurface Sewage Disposal System-Page 12 of 17 26 a5ed xej dH 9b-b6 RI,02 £Z unr c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y'y 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name information is required for every Centerville MA 02632 6-22-18 page. CityfTown State Zip Code Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number: ❑ 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.): Over flow is a old Fff Block Pool. Over flow is dry w/cement cover at 22"below grade.Wall's are solid and clean. No sign of over loading or high stain line. Al Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth —top of liquid to inlet invert 2 Depth of solids layer 6" Depth of scum layer 2 Dimensions of cesspool 6x8' Materials of construction Old Block Indication of groundwater inflow ❑ Yes ® No 15ins.doc•rev.6118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 6 abed xed dH Lt,:b I• 81,02 S2 unr Commonwealth of Massachusetts. F. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Rolling Hitch Road ,V- r Property Address Stephen Botello Owner owners Name Information is required for every Centerville MA 02632 6-22-18 page, CityfTown 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.): Main pool is Vx&w/cover at16". Pool is solid w/oullet tee Level in pool at 2' below inlet 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.): t5ln3.doc-rev.6/16 Title 6 Offidal Inspection Form:Subsurface Sswage Diepoasl System•Pape 14 of 17 b abed Xed dH Lb:b I, 8l•02 EZ unr Commonwealth of Massachusetts Title 5 official Inspection Form " Subsurface Sewage Disposal System Form•Not for Voluntary Assessments E 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name Information is required for every Centerville MA 02632 6-22-18 page. Cityrrawn State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A (�EPP- Q 0 31 3' 151nS.Coc•rev.61116 TiUa 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 5l abed Xed dH &b 1. 860Z £Z unr c Commonwealth of Massachusetts VTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tz::5W 19 Rolling Hitch Road Property Address Stephen Botello Owner Owners Name information is required for every Centerville MA 02632 6-22-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO 11' Estimated depth to high ground water: feet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® Observed site (abutting propertylobservation hole within 160 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: Auger T.H. 1 T no G.K. Bottom of over flow at T below grade, Bottom of over flow at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mns.doc-rev.6/16 TIUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 g l, abed xed dH Lt,:b 6 8 60Z EZ unr 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Rolling Hitch Road Property Address Stephen Botello Owner Owner's Name Information is required for every Centerville MA 02632 6-22-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B. C, D,or E checked ® inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.dcc•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systsm-Pape 17 of 17 abed Xed dH Wt 6 860Z £Z unr pp ` TOWN OF B STABLE LOCATION h�`` A SEWAGE # VILLAGE ���v 1! � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE iNO. P�J � r�l L O. SEPTIC TANK CAPACITY _ �O G R' t �` • ' LEACHING FACIL]TY: (type) (size) 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) Feet Furnished by -� ��-�j .� , , a� �'' � � o � � �y � �-_, I 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 j PART A CERTIFICATION Property Address: ( _ a /�/,c/ fl//-Cff'44-h, keo I (f �e2.0 -nil5mit 1 e,, f Owner':Name: Owner's Address: Q Q s� 0 Date of inspection; Name of Inspector:(pi priat) �j� Compamy Name: . .!i CJ J�ic7,f 3 V;a Malting Addtt ess: S i+1® O, j Telephone Number. �l CERTIFICATION STATEMENT I certify that t have personally inspected the sewage disposal system at this address and that the information reported below is nue,accurate and complete as of the time of the inspection.The inspection was performed based on my ftining and experience in the}roper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: _ Date: f�� /L o?oo 9 The system inspector shall submit( opy of this i spection report to the Approving Authority(Board of 1 leaith 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;,neater,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 a.Rd 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 1 conditions of use. i � 1 .Page 2 of I I' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT 'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address• A c� A eq�(S 4C/f Owner so2C43a /Z°. �' 7/-t v s 7-r� Date of Inspection: /C 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 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. CMR Comments: B. System Conditionally Passes: e or more system components as described in the"Conditional Pass"section need to be replaced or repay system,upon completion of the replacement.or repair,as approved by the Board of Health, wi 1 I pass. Answer yes,no or n detumined.(Y,N,ND)in the for the following statements.If"not determi please explain. The septic tank is meta d over 20 years old*or the septic-tank(whether me or not)is structurally unsound,exhibits substantial M 'on or exfiitration or tank failure is immine . ystem will pass inspection if the existing tank is replaced with a comp . g septic tank as approved by the B of Health. *A metal septic tank will pass inspection it is structurally sound,not ing and if a Certificate of Compliance indicating that the tattle is less than 20 years o is available. ND explain: Observation of sewage backup or break or high tic water level Jn the distribution box due to broken or obstructed pipe(s)or due to a broken,settle r uneven distribu ' n box. System will pass inspection if(with approval of Board of Health): roken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: TLe in required pumping more than 4 times a year due to broken or obstructe (s).The system will pass ins on if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i .ND explain: j I Page 3,of 11.. 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TS PART A CERTIFICATION(continued) Property Address: � Owner: v Date of Inspection: ..`�/t vJ'%rJ'2 C. Further.Evaluation is Required by the Board of Health: Co 'Uons exist which require further evaluation b the Board of is failing to protec lth,safe or t y Health in order to dete ' ty he environment. a system l• System will pass.,unless Board of Health determines i system is not functioning in a manner which r i5.303(1)(b)that the protect public health,safety and the envtro , _ Cesspool or privy is wi eet of a surface water Cesspool or Pri thin 50 feet ofa bordering vegetated wetland or a salt marsh l. Z- Sys Willi fail unless the Bos q5UM istunetiu of Health(and Public Water Supplier,if any)determines that the aiing in a manner tha teets the public health,safety and environment: The system has a septic tank and soil ab tion system(SAS)and the SAS is within 10 et surface water supply or tributary to a surface Ovate ply. of a — The system has a septic tank and SAS and the SAS is in a Zone 1 public water supply. T e system has a septic tank and SAS a6d the SAS is wi . � 0 of a private water supply well. The system has a septic tank and SAS and the is less than100 b 0 feet or more from a Private water supply well". Method used to d rmine distance ]00 feet "`This system passes if the well wat nalysis,performed at.a DEP cenified laboratory, fo liform bacteria and volatile organic co unds indicates that the well is free from pollution from that ili the niter a amammonia n' gen and nitrate nitrogen is equal to or less than 5 ty and failure criteria are tri A co of the analysis must be attached to PPm.Provided that n copy y this form. then 3. O er: , Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• w I re ,C ti Owner: �t 7Z IV)I -c Date of Inspection, c 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 move 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 f 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 I 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 coliform bacteria and volatile organic compounds indicates that the weg is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to orless than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) K_(YesINO)The system faits. 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 Sy tems: To be considere rge system the system must serve a facility with a design of 10,000 gpd to 15,000 gpd. You must indicate either"yes' " o"to each of the following: (The following criteria apply to large sy in addition to the cr' to above) yes no — _ the system is within 400 feet of a surface inking water supply the system is within 200 feet of ibutary to a surface drinking water supply the system is located ' nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a publi r supply well -` If you have answere es"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section bove the large system has failed.The owner or operator of any large system considered a significant thr t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ; Property Address: Owner: SJ (Y. Date of Iaspeetion: L ��� Jd " Check if the bllowi ig have been done. You must intricate` es"or"no"as to each of the followin : Yes NQ - ,/Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the Previ ous ous two weeks? Has the system received normal flows in the previous two week period? — .v/-�Have.large volumes of water been introduced to the system recently or as part of this inspection? JZ T Were as built pleas of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for si gos of sewage back up? Was the site inspected for signs of break put? i Were all system componen W / ��aWthe SFAS, S,located on site? _tL — Were the septic tank manholes uncovered,open and ` or toes the Interior of the tank inspected for the condition ,material of constivetion,dimensions,depth of liquid,depth of sludge and depth of scum ? r— was the facility owner(and occupants if different from owner)provided with information on the proper mauuename of subsurface sewage disposal systems,? T e sin and location of the Soil Absorption System(SAS)on the site has been determined based on : Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria relate ys unacceptable)[310 ChIR 15.302(3)(b)J d to Part C is at issue approximation of distance • i Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property-Address: � ,L d Owner.- 770 W Date of Inspection: '/ LFO CONDITIONS RESIDENTIAL Number of bedrooms(desi gn):gn): Number of bedrooms(actual): DESIGN flow based on 310 CMt 15.203 (for example: 110 gpd x it of�edr_ooms):WOLGP/P Number of current residents: 0 Does residonca have a garbage grinder(yes or no):JI JO Is laundry on a separate sewage system(yes or no):L . [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): l JO 'O N 6 CG s jI a d 4 t" 4W,41& Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(m or no): Pb , Last date of occupancy: ryl e;cr 7),f �l COMMBBCLUJIMUSTRIIAL Type1 �✓ Design fl d o&310 CMR 15203)r pod Basis of design flow(sesis/perso Grease trap present(yes or no):_ I Industrial waste bolding-tank prese es or no):_ Non-sanitary waste o the Title S system(yes or no): �- WaLmmar available: — Last date of /use: {descn'be): GENERAL INFORMATION Pumping Records /� :z.rl SW=of infor madon• N Q (`ery 0,UU P�r� Was SYMM pumped as part o inspection(yes or no): If yes,volume pumped: allons—How was quantity pumped_determined? Reason for pumpbW r�S S V y TYPE OF SYSTEM o S ptie tank,distribution liox,soil absorption system ingle cesspool �verflow 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) . T Tight tank `Attach a copy of the DEP approval Other(describe): Approxhpate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): I`�� Page 7 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -y/f el/�i ��,Q,� d,s Z ,ram' u 1 Owner: `1 G h /f $ea� . Date of Inspection:07 �- _ i BUILDING7:ondti vate on site plan)Depth belowMaterials of :_cast iron 4 _other(explain):Distance froter su or suction line:Commem(o mints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth _ Material of oanstrt concrete metal fiberglass — �ass__polyethylene: Iftaalc is noetal list age:_ Is age to of Co (yes or no):—(attach a copy of catiftcate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outl a or baffle: Scum thickness: Distance from top ofseut to top et tee or baffle: Distaioe ftm bottom of bottom of outlet tee or baffle: How were dimensions Comments(on p ng recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to et invert,evidence of leakage, etc.): GREASE TRAP:_(I site plan) Depth below grade: Material of construction:_concrete_metal—fibe ethylene—other (explain): Dimensions: Scum thic�ess: Distance from top of scum to top of et tee or baffle: Distance from bottom of sc tiom of outlet tee or baffle: Date of last pumping: Comments(on pu ' g recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid lei as related to et invert,evidence of leakage,etc.): e ,Page 8 of I 1 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORM,,TION(continued) Property Address• O �4.j _ Owner: 0 ;r-PDate of Inspection: Ast1i �vslr-e TIGHT or'HOLDING TANK: (tank must be pumped at time of inspectionxlot:ate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene ocher Dimensions.` gym'; allons Design lons/day Alarm present(yes or no): Alarm level: Alarm in working o es or no : Date of last pumping: Cotnntertts.(condition of al d float switches,etc.): DISTRIBLM0N BOX: t must be e on site plan) Depth of liquid level above outlet invert: Comments(note if box is level stribution to outlets equal,any evidence of soli s ca l�ge-mtoOr'outofbo evidence of PUMP CHAMBER: (locate on site plan) i Pumps in working order(yes or no): Alarms in working order(yes or no Cow(rote condition o p chamber,condition of and pumps apptuteuances,etc.): ,Page 9 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Cr Owner. o p Date of Inspection• vV" SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not loo�tteed explain why: Cl U(w-- �(p .0 eSJ -e Pe 04.� s j ! ,I'rpe Srta Nam. 15 NoJ �v T.-) s� '-XVd - rl� raj leaching pits,number., +Eta caching chambers,number: leaching galleries,number ling mwchM number, length: -l�m8 fields,number',dimensions: overflow cesspool,number: '"novativtlalerwive system Type/name of technology: Con'mcets_(note edition ofsoi etc.):), 1,si gns of hydraulic failure,level of ponding,damp soil,condition of vegetation, t'�/L-•FLc�u� ��'ssPoc�f w ad S © �SF�4'w Qzst��ed cvoc�tC �. �Zjd CFSS Ie.� NWO&SC): (cesspool must be pumped as part of in sped on)(loca e on site ��` LAJA,5 r pat') Number and configuration:--0&3f•- 6 Depth—top of liquid to inlet invert: Depth of solids layer Depth of scum layer: Dimensions of cesspool: L LC4A,yp t 0 c� B/Ocir C tP sS/a d 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 Materials of construction: t Dimensions: Depth of solids: Comments(note condition of s ', tgns of hydraulic failure, level of ponding,condition of vegetation,e I Page 1 o of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,p ,':_,bA �►7:,; . s� > Owner: d 00I63 . Date of InsIp- do 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. 10, E-eSS Poa 4cnN� A-,S �Pep—IP `tom — I Jd XO- 4400,vd- aorld r No Page 11 of 11 ' OFFICIAL INSPECTION . ECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: d��/.�/ � ���, Zw Owner: /� Date of Inspection: �-`�' SITE EXAM Slope Surface water Check cellar Shallow wells U' 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: f You mast describe how youptablished the high ground water elevation: o tz& e ®(5d t c-LnE� sd. 43 -� � ✓' YOU d � ® o a l a v • d ` d L elf �� 1 A2C LCA-q_C&AJ r �+ AFFIDAVIT I,J.Douglas Murphy,an individual residing at I I I Wild Goose Way,Cente rville,Barhsta County, Massachusetts on oath depose and state: a, 1. I am one of the children of Henry L. Murphy and Mary E izabeth Murpta, both late of Centerville, Barnstable County, Massachusetts. .p: > N M 2. I have resided in Centerville since 1952. 3. My parents purchased the property at 19 Rolling Hitch Road, Centerville, Massachusetts in 1978 from Mary Alice Cusick. 4. At the time my parents purchased the premises at 19 Rolling Hitch Road, it was improved with a single family dwelling which had been constructed by Chuck Stanley some time around 1971 or 1972. At the time I believe this home was constructed,I was employed as a Real Estate Broker in the Town of Barnstable, and was familiar with Chuck Stanley's residential housing development on Rolling Hitch Road in Centerville,MA. 5. Attached hereto is a sketch plan entitled"19 Rolling Hitch Road Centerville Floor Plan Sketch" which depicts with reasonable accuracy the layout, number and identification of the various rooms on the first and second floors of the premises at 19 Rolling Hitch Road, Centerville, MA 6. To my personal knowledge this is the same layout and room identification of this dwelling as that which existed when my parents took occupancy in 1978. 7. To the best of my knowledge,recollection and belief the attached sketch also accurately depicts the layout and identification of the various rooms of the first and second floors of this residential dwelling when it was constructed and offered for sale on or about 1971 or 1972. 8. The foregoing statement is a true statement of facts known to me except insofar as is stated to be upon information, recollection or belief and as to those statements I believe them to be true. WITNESS my hand and seal as of this day of September, 2009. A J. Douglas urphy Sep 28 09 01:18p JAMES E MURPHY, INC. 5084280802 p.2 s� t (got. .. ........... A .l !A •i _ i v .tea 40 NO j IV) K- c.t i i e .I x ING Y ACTION CESSPOOL, CAPE�ABOY .. SAGAMORE,MA 02561 Iiissstttiisiitsitittittittiltti ----------