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0084 ROLLING HITCH ROAD - Health
84 Rolling Hitch Road Centm lle P A = 192 082 No. 42101I3 O A 17 1000 u No. r/ l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes ftPhLation for Ne-poSAY 6pstrm Cunstruttiun Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. 94 1 1Ne- ►fiC Owner's Name,Address,and Tel.No. 1 Assessor's Map/Parcel f 9 Z 8 Z �E t I SU Pj——7.7 S- 1?�) 2 Installer's Name,Address,and Tel.No. '��y(y�l(L G'pT, Designer's Name,Address,and Tel.No. 0 (PdWEZL (Z 60401-14PrO25-3G N� Type of Building: S�$�Z Dwelling No.of Bedrooms 3 Lot Size �3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank/s r/ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �E��A-(C �X 1 ST W 6- T) 'n4 I EW 6Z SEA- - LU vq_�lz -fv 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 Certificate of Compliance has been issued by this Board of Health. J Si Date �/ Z Application Approved by Date 2 Application Disapproved by Date for the following reasons Permit No. ���' 06 � Date Issued 1- a r� s No. Fee�. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes , ftplitation for 33isposal *pStpm ConstrULtion Ve>'mit a Application or Permit to Construct( ) Repair(� Upgrade( ) Abandon_( ) Complete System .`�Individual Components Location Address or Lot No. V6 iN&, %f r- Owner's Name,Address,'and Tel.No. �/ � VIIIC, 3, Assessor's Map/Parcel 1 $ Z 8 Z lF�tR �U�_ "'�-7 5% ?*1 Z- tZ' Installer's Name,Address,and Tel.No. J2AAf &'(Z-- 7, Designer's Name,Address,and Tel.No. Type of Building: 2 �L 55 ut_ Dwelling. No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) MOther' '¢} Type of Building `No of Persons Showers( ) Cafeteria( ) ,.7 � ... x.. ,K_ 's.... _ ..-y,•¢„, .. �Sv':- .,.,r:.. .�r.: _ s+*sr.:a r.n:.:....�«. � biher,Tixtures Design Flow(min.required) gpd Design flow provided trn gpd r. Plan Date Number of sheets Revision Date 1 t t Title Size of Septic Tank f ,Y! Type of S.A.S. L l!; i� i /� X)S IV , Description of Soil t;. . . Nature of Repairs or Alterations.(Answer when applicable) V-'f LAt f>` .1 a , NCr ' • /b/ W 7. v ' a X ,. ,'S E ;z -- c'u kr+-tz- fir Cr 6(7-n o•C- a Date last inspected: -° Agreement: �l t t . ' s, The undersigned agrees to ensure the construction and maintenance,oithe 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 Certificate of Compliance has been issuedlbylthis�Bgard of Health Sigped A ✓.-.r Date A lcation A roved b f Date ./pP. Pps. Y �r c� _.. n° _.v Application Disapproved by v Date for the following reasons Permit No. "'� 0 1 Date Issued - - ----- -- ----------- ------------- THE COMMONWEALTH OF MASSACHUSETTS s �J%1�u BARNSTABLE,MASSACHUSETTS t ; (Certificate of �o1nYiarlie d THIS IS TO CERTIFY,that the�Ori-site Sewage Disposat system Constructed( .) Repaired( �') J Upgraded( ) Abandoned( )by f41 1"'' t;..r` y S S iL l T.Id N� at `'( wo!L i, 6- /4 [4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.J,�' V dated S/ Y: Installer -, /!�/Vy 1� +jj' r - Designer #bedrooms Approved designs fl-o�w�, � �/1!� gpd The issuance;of this 71' t shallnot be construed as a guarantee that the system will functions asdesignedDate t d Inspector V y e't...'+.v ;.. .._,•..:...yi...a . -•.rvnv ..r*.. -.F.. .... »V— No. ,�t ° 06 '1 Fee THE COMMONWEALTH OF MASSACHUSETTS '- PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal *p 01YStrUttiou 'permit Permission is hereby granted to Construct( ) Repair(` Upgrade( ) Abandon( ) System located at' !-c�111�//G� /-r 1 � rr A/T,Ere- V I t ('f' and as described in'. n the-above Application for Disposal System Construction Permit.*The applicant recognized his/her duty to comply with Title 5 and the following local provisions'or special conditions. N j Provided:Construction must be completed within three years of the date of this permit. Date e /.,2 / Approved by r 12 C SHF Town of Barnstable TQ� Inspectional Services Department ti r BA ATABLL SS.MASS. Public Health Division M 039. �' iOjFa " 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8104 March 3, 2021 ELKINS, WILLIAM & MYRNA L TRS 84 ROLLING HITCH ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 84 Rolling Hitch Road, Centerville, MA was inspected on 02/17/2021 by Michael T Bisienere, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted and needs to be replaced. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. P ER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\84 Rolling Hitch Road Centerville.doc �.z►+aE roy, Town of Barnstable 9 Ik k t63q• Inspectional Services Department �0 prFDN1`�A Public Health Division 200 Main Street, Hyannis MA 02601 Office:ce: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x'' marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA o Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems'' (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 19a o�� c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd V� Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. filling out forms A. Inspector Information �! j�►(Q filling out forms on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name .key. 52 Rivers End Road Co f� Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ® Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails. 4271-- / 02/18/2021- In pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts f = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 84 Rollin Hitch Rd —L g Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ 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: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts - ,p Title 5 Official Inspection Form +� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6-P` 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval, if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ?� w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: This 3 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding a precast leaching pit. At the time of the inspection the D-Box had root infestation and signs of decay. I recommend replacing the D-Box. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS,WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form + "i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is Centerville MA 02632 02/17/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If es discharges to: Y 9 Is laundryon a separate sewage system? Include laundry system inspection P 9 Y ( rY Y P information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Town water Detail: In 2020 -72,000 gallons were used and in 2019-95,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS,WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24"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: H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 l c Commonwealth of Massachusetts - = Title 5 Official Inspection Form +� i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At the time of the inspection the D-Box had root infestation and signs of decay. I recommend replacing the D-Box. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts M1 = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �n 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c� Commonwealth of Massachusetts - Title 5 Official Inspection Form jm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd Property Address ELKINS, WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 84 Rolling Hitch Rd v� Property Address ELKINS,WILLIAM & MYRNA L TRS Owner Owner's Name information is required for every Centerville MA 02632 02/17/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections.of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r t CONIAIONWEALTII OF MASSACIIUSL•'1'1'S ..UxU'1'IVE OFFICE OF E NVIRONML:N'I'AL ATFAIRS _ DEPAKT'11IENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION F OR SUBSURFACE WAGE DISPOSAL S STEn FOIIAJ viENTS PART A I O1t11I CERTIFICATION Prop'erty Address: 8 4 Rolling Hitch Road en ervi e Owner's Name: Rona ezzano Owner's Address: -( +�c� �� OC o r1_ llatc of Inspection:_ Name or Inspector.(please print) Sean Jones CompanyNamc: William L_ Robinson Septic Service �iailing Address: P O_Box le llil Telephone Numbe-C�tttervil r, t SOfI I �S �77 f �.:<<_„ CERTIFICATION STATEMENT 1 certify that 1 have personally inspected die sewage disposal system at this address and that tine info below is true,accurate and complete as of die time of the inspection.The unspection was perfornhed based on nhY rohation reported training and experience in die proper function and maintenance of on site sewage disposal systems. 1 our a UEt� approved system inspector pursuant to ction 15-340 of Title 5(310 CtUlt 15.000). 71te system: Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fa Inspector's Signature: �^ Dutc• The system inspector shall submit a copy of dhis inspection report to Ole Approvuig Authorit y(Board of Ilealdh or UCP)-within 30 days of completing this inspection. If Ole system is a shared systcnt or has a design flow of 10 0UU gpd or greater,die inspector and die systcnt owner shall submit the report to die a ro nale regional office of die PP p re g ffi LP.711c original should be sent authority. lu(Ile system owner and copies sent to the buyer,if applicable,and die approving Notes and Continents "This report only describes conditions at the bloc of inspcclion anti under the eouditions of use at that lime This inspection does not address ho++'file SPUR] will perform in the future under[lie same or different conditions of use. Title S Inspection Form 611 Y2000 page I Page 2 of I I OFFICIAL,INSPECTION FOIIM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 84 Rolling Hitch Road Centerville Owner: Ronald Mezzano Date of Inspection: ,P t gvD(o Inspection Summary: Check A,B,C,1)or E/ALWAYS complete all of Seclion 1) A.7,xlc passes: not found any u"t[oruutwn whidt indicates that any of the failure criteria described in 310 CMII 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated arc indicated below. Comments; U. System Conditionally Passcs: t" I'A One or more system components as described in tire"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair.as approved by the hoard of 1lealtlr,will pass. I Answer yes,no or not determined(Y.N,ND)in the for the following statements.If"uot determined"please explain. The septic lank is metal and over 20 years old'or the septic lank(whether metal or not)is structurally unsound,exhibits substantial infiltration or cnfiltration or tank failure is imminent-System will pass inspection if Utc existing tank is replaced with a complying septic tank as approved by the Board of llealth. •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 titan 20 years old is available. ND explain: Observation of sewage backup or break out or higli static water level in die distribution box due to broken or obstructed pipe($)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of health): broken pilic(s)are replaced obstruction is temi3ved distribution box is leveled or replaced ND explain: The system required pumping more titan 4 tirues a year due to tnvkcn or obsbuctcd pipc(s).11tc s)stcnt will pass inspection if(Willi approval of the Board of Ilcalth): broken pipc(s)arc replaced obstruction is t>`moved ND explain: r j +Page 3 of I I OFFICIAL INSPECTION I?01M- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE: llISPOSAL SYSTEM INSPE'C"PION FORM PART A CERTIFICATION(continued) PropertyAddress: 84 Rolling Hitch Road Centerville Owner: Ronald Mezzan Dale of Inspection: a -1,/-, ' ' '� ('�' k" C Further Evaluation is Kcquired by the Board of Ilealth: � A Conditions exist which require further evaluation by the Board of I Icalth in order to determine if the systcm is failing to protect public l,ealll,,safety or the environment. 1. Systen►will pass unless Board of Health determines in accordance with 31 0 Cult IS.303(1)(b)that the system is not functioning in a manner which will protect public health,safely and (lie environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feel of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Ilealtl,(and Public Water Supplier,if any)determines that like 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 die SAS is within, 100 feel of a surface water supply or tributary to a surface water supply. The system has a scptic tank and SAS and the SAS is within a Zone I of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well,• Method used to determine distance "This system passes if the well water analysis,performed at a DEl'certified laboratory, for coliforn, bacteria and volatile organic compounds indicates that the well is Gee from pollution from 11}al facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppn,,prov- I that no other failure criteria are triggered.A copy of the analysis must be attached to tllis fornl. 3. Mier: Pagc 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIIIENTS SUBSURFACE SENVACE DISPOSAL SYSTEM INSPECTION FORA PART A CL10"IFICATION(continued) Property Address: 84 Rolling Hitch Road Centerville _ Owner: Ronald Mezzano Date of Inspection: r �e D. System Failure Criteria applicable to all systems: You muAindicalt"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage unto facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of cMucm to tine stufacc of the ground or surface waters due to an overloaded or clogged SAS or cesspool Stalic liquid level in the distribution box above outlet invert due to an ovcrluadcd`ur 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 widnu, 100 feet of a surface water supply or tributary to a surface water supply. __—_ Any portion of a cesspool or privy is widnin 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 feel front a Inivale water . supply well will,no acceptable water quality analysis.(This system passes if(Ire well water analysis, performed al a DEP certified labora(ory,for coliform bacteria and volatile organic compounds indicates that lire well is free front pollution from that facility and (he presence of ammonia nitrogen and nitrate nitrogen is equal(o or less than 5 ppnr, provided that tv other failure ct itcn is arc triggered.A copy of(Ire analysis must be attached to(his form.) AID (Yes/No)The system fails. 1 bave determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system ow'tner should coutact the Board of I Iealth to dclennine what will be necessary to correct the failure. E. Large Systems: To be considered a large s3 ern rite system must senNe a faci!i(y with a design now of 10,000 gild to 15,000 gird. You trust indicate either"yes"or"no'•to cadh of the hollowing: (llie following criteria apply to large systents in addition to the criteria above) yes nu the system is within 400 feel of a surface drutkutg water supply — _ tine system is within 200 feet of a bibutary to a surface drutkin&water supply _ — the system is located in a nibogen sensitive area(Interim Wellhead Protection Area—IWVA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any qucstiun in Swui m E lite systeut is unuidcied a siynifiLant ducat,ur ajk.N rcd "yes"in Scction D above the large system has faikd.llte ow-n:r or optralor of airy large system considered a significant ducal under Scction 1:or failed under Section 1)shall upF.rade tl,e sysicrn in accordance wilh 310 Chill 15.30-1.Tine sys1cm outer should cvN rLt lh:• alyuvlaiatc regional oflicc of the Ucpailnncnt. IagcSofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOIJAI PART B CHECKLIST Property Address 84 Rolling Hitch Road Centervi e Owner:_Ronald Mezzan Date of Inspection: t n Check if the following have been done.You must indicate' es"or"no"as to each of the followin : l'cs/ No `�/ _ Pumping information was provided by the owner,occupant,or Board of Ilealth 4werc any of the system components pumped out in the previous two wee ks 7 _ Has the system received normal flows in the previous two week period? I lave large volumes of water been introduced to'die system recently ntly or as part of this inspection? • � L / Wcre 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 sewa ge age backup , ,T Was the site inspected for signs of break out? Were all system components,excludingthe SAS,AS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the f(les or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 7 Was the facility owner(and occupants if different front 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: l'cs no II TExisting information. I-or example,a plan at the Board of health. '✓ _ Determined in the field(if any of the failure criteria related to I art C is at issue approximation of distance is unacceptable)13 10 CMR I5J02(3)(b)J ti 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE\VAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR1ViATION Properly Address:84 Rolling Hitch Road Cen ervi e Owner:_Ronald Mezzano Dale of Inspection: , coo FL 1V CONDITIONS RESIDENTIAL Number of bedrooms(design):A Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): .4 Ljo P'b Number of current residents: 3 Does residence have a garbage grinder(yes or no): /Va Is laundry on a separate sewage system(yes or no):VD [if yes separate 41spcctiort required) Laundry system inspected(yes or no):MA Seasonal use:(yes or no): ND Water meter readings,if available(last 2 years usage(gpd)): 2005 — 129,000 Sump pump(yes or no): NO — , 0 0 0 Last date of occupancy: COMMERCIAL/1NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design now(scats/persons/sg1`1,ctc.): 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: -e� Was system pumped as part of the inspection(yes or no): 6Lo If yes,volume pumped: gallons--How was quantity pumped d0cimincd? Reason for pumping: TtPOF SYSTEM _ tic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Pricy —Shared system(yes or no)(if yes,attach previous inspection records, if arty) _Innovative/Alternative technology.Attach a copy of die current operation and maintenance contract(tu be obtained from system owner) —Tight" —Attach a copy of die DEI' approval —Other(describe): Approximate age of all components,date urstallcd(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): t I'af,c 7 of I I OFFICIAL INSPECTION FORM — NOT FOIL VOLUNTARY ASSLSS61LNTS SUl1SURPACF NEWAGE DISPOSAL SYSI.1-- 1 1NSITC CON F0101 PART C SYSTM INF0101ATION (curttinucd) Pruptrlp AJJrtss: _ 84 Rolling Hitch Road Centerville Owner: Ronald Mezz no Dalt of Inspt(l UUILUING SCWCIt(lucatc vn silt plan) Ucptl,below glade:_ a�.. � � �•• Malcrials of conslrucUon:_cast hull ZA/UI'VC_utlrcr(explain). Distance frunl private scaler supply well or sutliun line: -- Cumnscros(un condition of)uu,ts,vu,ting,cvid(ncc of IcAal;c, cl(.): 4 LG4 SCI'TIC TANK-.�localc on silt plan) Ucpll,below grade: f`tatcrial of constructiun: t/cvitctctc nictal Gbcrglass �wl)tUtylcnc _uUtcr(cxplain) — — c irk is metal list age: Is agc cunli n t ,cd by a Ccrtilicalc of Compliance Ocs ut nu)'. n _(aacli a cup) of ccrtiGcatc) _ Dimcnsiuns: Uislancc froth lull of sludge to bortun,of uullcl Ice of balllc. 13 Sewn tl,icV,r,ess:_� ��_ -- Uislalm from lull of scum to lull of mullet Icc yr bafllc: _ "7 Dislar,cc from LuUvn,of scull,to bvnun,of uullcl'cc ur balllc: 1 3 r• llvw c�crc Jin,cnsivns JctcnnincJ. Qp�Ited Cd„t� awe/ ya,�✓_ W�faJ.,ir,b.c�t • Cununcnls(oil pumping rcconunclibliuns, inlet and vutict Icc of ba(Ilc cunJitit.n, stn,ctu,al intcl;,ity, Iiyu,J Incl.u related to u/ullcl ins•en,cvidcncc of (akage, etc ^k C- A'a-- fit[-/ y; —bL ^ 700iA Corr 7a .,AJ GIICASC TIIAI': _ lucalc un silt plan) 1)(110,bclu%v grade:_ hlalelial of eunsirueliun:_toi,ctcte u,ctal fibcll;lass _—pul)etl,ylcnc vll,er - -- Duncnstuns: — — --- — --- Scwn ll,icu,css: _ _ D,starlcc flute Iup of stunt lu lop ul oullcl Icc ur balllc: Distance (lull,bullurn of scull,Io l o1l.nn ul vullcl Icc or balllc— -- Dalc of last punlpinl;: ---- --- Cununcnts(un punynnl;IcconuucnJ,,l,un;, u,lcl amJ uullcl lcc t,r (Ialllc tur,'l,tn,.,, stiutlwal mtcl,,,l), I,yu,d Ir\tl, as rclatcd lu vullcl inec,t, ccnlcntc of icAff,c, cic ). 7 age /of I I OFFICIAL INS1'LCI'ION FORM - NUT FOIL 1'UI,UN7'Alll' ASSL`S111EN"fS SUUSURFACL•; WS'AG1; DISPOSAL S1'S-l•1.1-m INS1'I;C'I'I0N F(A(N1 PART C SYSTEM INFORMATION (cunlinucd) rroptilp Address: 8.4 Rolling Hitch Road ('Pn ryi 11e Owntr. Dolt of Ins1 / ittlloo: o a�a6 'FIG IIT or 110LUING TANK: 'V ' tanh n ,_( must tic I,unrpcd at lime of ins ucli I on)(lucate un sift plan) Depth below grade: h(alcrial of construction:__cun(lcic _nrclal _--(ibcrglass__)ulyclhyltrtc vthcr(cxplain): Capacity: s aI lull s Design flow: gallons/day Alarm prescnl()-cs ur no): Alum Icvcl: Alum in%vulkirs•b urd(r )cs ur n(� v Uatt of last lumping: ) -- Cununcnts(condition of alarm and fluat s%%itchcs,c1c.). UISTIUBUTION BOX: ____(tf prescnl must he vl,cncd)(lucalc on site plan) Depth of liquid level above uurlcl in%•clt: It ka nts(nine if box is CIt.eve and Jislribut on Iu vullcls equal,anp evidence of solids carryover, an eviden Iej�AaScnw or out of box,c1c.). Y ce of O✓ (yam G-4 4 c_ - ��Pl PUMP CIIAMBLII: (,,)(alc un site plan) Pumps in%corking urdcr(yes ur nv). _ Alarms in%corking order ()-es u( nv). _ Cvuuncnts(nulc condiliun iif pump chamlcl, sund1ln n „I lnnup, mill alynnlcnanres• (1c.) OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSIIIENTS SUBSURFACL SEIVACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 _Rolling Hitch Road. Centerville Owner: zzano Dale of Inspection: (o SOIL AUSOItI'TION SYSTEM (SAS): _(Iucn(e on site plan, excavaliou not required) -------------- If SAS not located explain why: Typ leaching pits,number: I _leaching chambers,number: leaching galleries,number:_ leaching trenches,number, length: ____leaching fields,number,dimensions: _____overflo"•cesspool,number: _innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, le etc.): vel of pondin ,damp suit, condition of vegetation So,I a.4s r v e e ` c 4 C tt L`a Lecq, -r s jam, CESSPOOLS:A(cesspool must be pumped as part of inspection) locate on( site plan) Number and configuration: Depth—top of liquid to inlet urvcn: Depth of solids layer: -- ' Depth of scum layer: -------- Dimensions of ce'ssPoul. Materials of construction _ _ Indication of groundwater inflow(yes — Conunents(note condition of soil,Sims of hydraulic failure, level of ponding,condition of%cgetation,etc.): PRIVY: N 1(loca(c on site plan) -- Matcrials of construction: Dimensions: --_ Depth of solid Comments(note condition of soil, signs of Irpdraulic failure, lCvcl of ponchng,condition of vegetation, 9 Pagc 10 of I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEINVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _84 Rolling Hitch Road Centerville Owner: Ronald Mezz no Date of Inspection: l aODSo SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of tic sewage disposal system including tics to at least two pennanent reference lanchuarks or benehrirarks. Locate all wells within 100 feet. Locate wiere public water supply enters the building. v � l 3 A_69 13-a: 7V, Ce�G� P 1- � r� � Ilagc 1 I of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTAItY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 84 Rolling Hitch Road Centerville Owner. _ Ronald Mezzano Date of Inspection: SITE EXANI Slope Surface water Check cellar Shallow wells Estimated depth to p ground wafer -5- feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked date o Observed site(abutting f design plan reviewed. 1 �S ( g property/observation hole within ISO feet of SAS) Checked with local Board of I Iealth-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: esr — J'/c II COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M 1 SV♦ TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASS7:RECEVED MEN SUBSURFACE SEWAGE DISPOSAL SYSTEM FOI PART A CERTIFICATION 2 2 2002Property Address: UC�(� / • N OF BARNSTABLEEALTH DEPT. Owner's Name: 1��G Owner's Address: :, � �+ Date of Inspection: MAP Name of Inspectftplease ) �� �• rC7'I-�'1Company.NameC,�L@7) e - PARCEL MailingAddressC)V �����. LOT �. Telephone Number: F5.7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was.performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems..I am.a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: !/ Passes Conditionally Passes N ds Further Evaluation by the Local Approving Authority its Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments t **** -. 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 6/15/20.00 page 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (p&/d WV Owner _ Date of Inspection: J00a Inspection Summary: Check A,B,C;D or E/ALWAYS complete.all of Section D �Istem 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: 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: 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: 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: - A Owner: Date of Inspection: 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. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from.a, private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified,laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION'(continued) Property Address: V :14�' Owner: Date of Inspection: 1�, C 00a D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No� _ v 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 lclogged SAS or cesspool Vp Static liquid level in the distribution box above outlet invert due to an:overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is Mess than 6"below invert or available volume is less than '/z 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. _ Any portion of a cesspool or privy is within,a Zone I ofa;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 106 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [.This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of:the analysis must be attached to this form.] U1q_(Ye9/No)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 mustserve a.facility:with it design flow of 10,000.gpd to 15,000 gpd• You.must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply a the system is located in a nitro en sensitive area(Interim Y b ( trim 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddress: Owner: Date of Inspection: � 90 Check if the following have been done. You,must indicate"yes"or"no"as to each of the following: Yes -o 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? V'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 backup �— Was the site inspected for signs of break out? V 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: Ye no — 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: c �d Owner: Date of Inspection: coo FLOW CONDITIONS RESIDENTIA Number of bedrooms(design):a.. Number of bedrooms(actual): DESIGN flow based on 310 C R 15.20�3 (for example: 11.0 gpd x#of bedrooms):�j? Number of current residents Does residence'have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or"no if yes separate inspection required] Laundry system inspected(yes or no Seasonal use:(yes or no): Water meter readings, if a ilable(last 2 ears usage(a d)): Sump pump(yes or no Last date of occupancy: �� COMMERCIAL%INDUSTRIALI!.� Type of establishment:: Design flow•(based on 310 CMR.15.203): gpd Basis of design flow(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:. oZ(�� Was system pumped as part of the inspecteo yes or no):/f6,& If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ ptic 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 _.Othei'(describe): - pproximate age of a�coyn.ponegts�,^date installer(if known and source of information: t� Were:sewage odors detected when arriving at the site(yes or o): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM..INFORMATION(continued) Property Address: ( ./ 64 Owner: 4Aj ' Date of Inspection: 260 67 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: locate on site plan) Depth below grade: lb Material of construction: concrete_metal_fiberglass_polyethylene other(explain). If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach.a copy of certificate) Dimensions: Sludge depth: N l/ Distance from top`f 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 botto of outlet tee or b�afpfle: _ How were dimensions determine : �.c� l�f1QPiSn . Comments(on pumping recomme dation/, inlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evidence of leaka&, ge,etc.): i� , �i GREASE TRAP:z"(1ocate 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: . -� aVG�C1 B4 Owner: Date of Inspection: 0C9- TIGHT or HOLDING TAN1\C {tank must be pumped at time of inspection)(locate on-site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): .Date of last pumping: Comments(condition of alarm,and float switches, etc.): DISTRIBUTION BOX: Z(if present must be opened)(locate on'site.plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box etc.): , PUMP CHAMBER_(locate on site plan) Pumps in working order(yes or no): - r Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATIONN(continued) Property Ad ress:Owner: Date of Inspection: O-P SOIL:ABSORPTION SYSTEM (SAS): �ocate on site plan,excavation not required) If SAS not located explain why: TYPe .....--._...._. V 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,, CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool-. Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: v4 Owner: �2, J"Zr Date of Inspection: kLZ,4 Z 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. o 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f/ SYSTEM INFORMATION(continued) Property Address:A- ('/0 Owner: I c Date of Inspection: (�C/a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground,water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date.of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: __Checked with.local excavators, installers-(attach documentation) _V Accessed USGS database-explain: You must describe how you established the high ground water elevation Gli' .; II ll Permit{dumber: Da`e: Completed by:. � _ HIGH GROUND-W.AT,ER LEVEL COMPUTATION �� Site Location: ✓� /%y'' �/�`" Cell � � Lot No.. Owner:- .r ���/ /�� i�a —Address-- Contractor: C Cl'/l2� Contractor: ✓� ©TT/ C--7e� , Address: 7 c/ Notes:. STE. 1 . Measure depth to.water table. to nearest.111a-t.. ..... ........ .Date month/day/-year STEP 2 Using.Water-Level.Range Zone and In.de.x WeIl-N:a.p.locate si.te_an.d'determine: 504) ZS z- O A.ppro.priate.index weli................_................-..........._........ —_1, CWater-level range zon........................... .......... _. ST P;:3r. Using monthly.repart:.•"Current �• I- Water Resources Conditions" ; determine current-de:pth'to water level for'inde)X well ........................... month/year STEP. Using,Table.o.;•Wate ;level Adjustments for index well (STEP 2A)_currant de:oth to water'level for.index wel.l ('STEP 3)., and water-level zone (STEP•26) determine'water level'adjustment ............................................-...................................... ...._. STEP: 5 =stimate depth to:high water by subtracting the water-; level adjustment-(STEP 4�) from measured.depth to.water C� level-at site.(STEP'1)' l r D Figure. ugh,�r a P tv, i I� I I i " I i. of � i 0 i 4q Tts r- Ld' �n IV �-,AcN fib" z-P,sT -. 3 3 v/r eo" ,�" �. ,� `•` �� �� L.o r #/8 B Za7-*/B i9�e /7 c v Z3 O 7%WX 2'• W O Z,,7 W/6 �o 23 10 zo, N 4s 7r1 of Pfl �10 ,��,���o.v = 6/..moo �,• � 1 t � 0 1U t L►I� � It t �oGG i�G /ud,-e— eu-yYg77a N s BA-s&-o o n/ LOCATION re-le V/GL& SCALE . .-.30 . . . . DATE . . . . . . . . . . PLAN REFERENCE /,�sl� ot,:�, ./�?yQ; N.9-�.Fa� LoT /8 s.44�w•v L-LLEY M 23100 Q h �vISTEg e . . . . . . . . . . . . . . . . �qNo su�VEyo I CERTIFY THAT THE . . SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. DATE : . . . . . ... . . . . . . C</0ruL&S F. SXq-"Ley - Ae77770AI4-;��> REGISTERED LAND SURVEYOR TOP OF FOUNDATION CONCRETE COVER T °;° CONCRETE COVERS 3.19� 0 4"CAST IRON 2"MAX. OR SCHEDULE 4� 12"MAX. ' I P.V.C. PIPE 4��SCHEDULE 40 P.V.C.(ONLY) 1j PITCH 1/4"PER. PIPE - MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST e.° INVERT a LEACHING o EL SB.3/ PIT OR INVERT INVERT ? • � SEPTIC TANK s gs DIST. r a , . w �;c EQUIV. o INVERT EL...7: . . . .�6 80X EL...7 . ..• ' w w 0: .�. S8 /Soo EL......7 6 ko 0: WASHED e; EL.....•./P... GAL. INVERT INVERT ` 3/4 TO I I/2 ,. w STONE T /5'—�+-W DI A. PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY : DATE F...4, TIME.Z:oo PH., .T�!ti►�s !�. �O^!Lo^! BOARD OF HEALTH TEST HOLE I TEST HOLE 2 �DtNiJ720 E', ?LC&_A E)! , , ENGINEER ELEV. .4o..30. . . . ELEV. .G�..Z4. . W000toAr1 WooDLo.Ary �„ Sc.B-Solt- 36„ s�o so/ DESIGN DATA : &Z.S7 80 � ��Z,, NUMBER OF BEDROOMS G2AVeL48 C,egV&7- In. n130 EZ. 67,Z.o TOTAL ESTIMATED FLOW . . . ., GALLONS/DAY FBOTTOM LEACH I NG AREA ��3/ . SQ.FT. /PIT/6, P,.D, Cogvzc CoArzSE SIDE LEACHING AREA . . .??`•.? SQ.FT./ SRr/p Sf}up GARBAGE DISPOSAL . y . . .(50 % AREA INCREASE) TOTAL LEACHING AREA 3`3/.•.3 . SQ.FT PERCOLATION RATEA"!. 9. MIN/INCH LEACHING AREA PER PERCOLATION RATE �7L': SQ.FT�C,P.D, A/d. .WATER ENCOUNTERED NUM BER OF LEACHING PITS . . . . APPROVED . . . . . . . . . . . . . BOARD OF HEALTH ! •f� aF S7a.v� o,./ ,qGL SiD�g , DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR C :r!� S•1:r � l- �i �• �r,t o T N �� ( F v F lL I ELI.._V r '`s o 52 IZaLGi!vC. .N�r1 Po'9� e4MC,STE�'' . A C'e7V74 P_ViG.L,r /19O5:5 PETITIONER C��q [� F ZTw"4&-�/ LOCATION �/�.�, �g� SESEWAGE PERMIT NO.v. VILL A GE � IN— S A LE 'S NAME i ADDRESS bo o� d U 1 L D E_R OR OwNER WA t46 P E R M,I'T� 1'S S,UjE D ` DA E° ` t0MPLIkNCE-�`I"SSUED T �� ,� Qoov, b ►' I � O op '1 t *THE COMMONWEALTH OF MASSACHUSETTS C� BOAR® OF HEALTH .l o.liv N OF...... a.�}iZ�/ST.!�.L3 G G1..................................... ApplirFa#inu for Disposal Works Toustrur#inn Frruti# Application is hereby made for a Permit to Construct (ri) or Repair ( ) an Individual Sewage Disposal System at: P0U_.1A1C /-111>-cN /ZD. G"G�.rT�i2l/icrLGl Z- T /7 Location-Address or Lot No. ......................—.......................................................................... -•••••--•--•-•-•--....--•-----•---._...........------•----•••-----•----........••................. W Owner Address Installer Address Type of Building Size Lot_.!-3,,.z'-Z---------Sq. feet �-� Dwelling—No. of Bedrooms..................................•...__._..Expansion Attic ( ) Garbage Grinder �wo aOther—Type of Building ______-_--•................. No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures . W Design Flow...............53 .......................gallons per person per day. Total daily flow-------------------- ...----------_........gallons. WSeptic Tank—Liquid capacity.!s o.gallons Length._Q'K Diameter________________ Depth.:!�'8."'_- x Disposal Trench—No. .................... Width.................... Total Length..................._. Total leaching area.................... sq. ft. Seepage Pit No......../.......... Diameter......Zz........ Depth below inlet..... \:. Total leaching area.-3.3 _3sq. ft. z Other Distribution box ( ) Dosing tank `-' Percolation Test Results Performed by---«!^-172-0 Gs:-.Je� :Ly................. Date...��— ...�/ Test Pit No. 1..C...L.....minutes per inch Depth of Test Pit---�6........ Depth to ground water-----_-------------- L14 Test Pit No. 2---j5;_Z....minutes per inch Depth of Test Pit.../3 K Depth to ground water------.............. a ............-••........-•--•-•---•-•--.....----•-••-•-------•----...•.................•-•-................................................................. 0 Description of Soil....... 30 wopj�4,4-,1 ' l3-so�c .............•- ........_ •-•--•----•-----...--•-•••------•-••-•-•-•--•-------•--...... -rzs ..----'SA�vz� W ••---•-•-•- --------------------------------------------------------------------------•---••----------------------------------------------------------------------•--•••-•-•-•--•----_..... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... { t Agre ement:" The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned furl er agrees not to place the system in operatiot�i until a Certificate of Compliance has been i , y the oa Signed.•-_--�-= ---•-••----------------;�,( off— ----------••-- ------•-- D--....... Application Approved B _ D to Application Disapproved for th llowing reasons:........... •--•---•-•--.Date............•. .........-•---•--•--•----•---•---------------•--•---------••--------•-•-------•--------------------•-------•--•-------------•----•----••--•-•---•---•--•---------•---•.._.........--•--•---•-----•------ Date Permit No.....vv.Q.-S. ------------------------- Issued------.... .............. Date No.....z ?`.1-3 T FIMs:--.. 4,Ca•� 2.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tonstrn•rtiun Permit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at: GdT 7 0 16 9 Location-Address or Lot No. ----------•--•-•---•-----•...•---•---•-••-----•-•••----•-••-------•-•............................ .......................................•......................................................... Owner Address W Installer Address d Type of Building Size Lot_-_._......................Sq. feet Dwelling—No. of Bedrooms.............. ..........................Expansion Attic ( ) Garbage Grinder (v) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria Other fixtures .----•----------=--------•-•-•-- . W Design Flow______________.`..._.........._.........--..gallons per person per day. Total daily flow..........334?...__..................gallons. WSeptic Tank—Liquid capacity!'s.'Q..gallons Length-e`G. Width. Diameter---------------- Depth'Q'g....... x Disposal Trench—No. .................... Width............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./........... Diameter.....�?......... Depth below inlet..... _........... Total leaching area.A31.3..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.. " Date..���? ._���....................... � Test Pit No. 1 ?'.:._..minutes per inch Depth of Test Depth to gIound water.____............_..44 \ Test Pit No. 2........ .._..minutes per inch Depth of Test Pit..« ......... Depth to ground water...."�.............. Q+' .-----••-•--•••-----•--••-----•.................•--------........---.........---._... D Description of Soil...... _��-30�" W00Dlo-4- % _OK S'u63-3oi� 30"-�8" G2.a-vL Z rzsE' SA�ir� U --------•-•-=------•-•----------•......-••----•..............•-•-------------.....---------•----•---•------••--•......--------------•---•--•••--•-----•--------------•--------------....--------------- W ---------------------------------------- ---------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•--------------------------•------------------------------•---•---•---------------...-•---------...----...-•----------------------------------------------------------------------------------....---•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 0 Signed...................................................................................... .......................... ate Application Approved By------ . -••--•-----•-------- ------------ •------ .......I;,--.4ate I Date Application Disapproved for a following reasons:...........................................................................�)- -.ss--------- •.........................•....•---•---•---------. ---••---------•.......------....... Date Permit No........ ..................�..3 -••------••- Issued--•------Z -�... ......2_:�................. THE COMMONWEALTH OF MASSACHUSETTS 1 t BOARD OF HEALTH Ta► ., B/�2NSTL><3LG ..........................................O F........................... .......................................................... (9rrtif irtttr of Toutplianr THIS"ToRTIFY That the Individual Sewage Disposal System constructed '(o'o) or Repaired by - ---------------••-•-----------------•----•---•---------------•---•---•---.............--------.......--••---•-•-------::.•••. Installer at �-f_ _-"•� �------F .A has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... .............. dated__.. __!Ps............. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. .............:�,! ----------------------------- Inspector............ -------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NO Okft t it GQtt�D�� L£Ect No...................... FEE........................ Disposal Works Tonstrnrtion "Permit Permission is hereby granted.............................................................................................. :: ................... to Construct (c/) or Repair ( ) an Individual Sewage Disposal System ----------- ---- t ------. at N ,.�'� �. > : + -••-- ------------ --------------------- as shown on the application for Disposal Wo s Construction Pe mI o. S__ l3 _ Dated.....Z_-.74 ..V-•2�-........... -------•--------------- - -----•...---- _ and a, DATE-------- - 5��------:'.......................... O FORM 1255 A. M. SULKIN, INC., -BOSTON