Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0197 ROLLING HITCH ROAD - Health
197 Rolling Hitch Road A= Centerville 4 1 No. 4210113 ORA ESSELTE lox 0 © O O 4, t wL Cornma veotfih of Massachusetts Executtve Office of Er Mrorvnerdat Affairs _ John Graci_.: -D.E.P. Title V Septic Inspector Department of - P.O:Boy 2119 Teaticket,MA 02536 Environmental Protection - (508) 564-6813 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION q/� L- V Property Address: 197 Rollin Hitch Rd.Centerville 1 P Y 9 Address of Owner: �7 Date of Inspectlon:.�119e . (If different) `yL9(' Name of Inspector:John Grad Freeman:12D4 Greendale Ave.Unita ham, � Company Name,Address and Telephone Number: le 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 compiete'as of the time of inspection., The inspection was performed based on my training and experience in the proper function and maintenance.of on-site sewage disposal systems. The system: X Passes _ Conditionally Passes: Needs Further Eval ation By the Local Approving Authority Fails Inspector's Signature:. - / Date: 8123198 The System inspector shall:submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a,.design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to theappropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found an information which indicates that — Y at the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below: B] SYSTEM CONDITIONALLY PASSES:. One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved aL by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(61T)556-1049 • Telephone(617)2924500 . 1 "` - "�... . S Wo .. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A - CERTIFICATION (continued) Property Address: 197 Rolling Hitch Rd cemerville Owner: Freeman:1204 Greendale Ave.Unit S 9 Needham,Me.02192: Date of Inspection:8121196 Sewage backup.or breakout or high static water level observed in the distribution box is due to a broken, - settled or uneven distribution box. The system will pass inspection if,(with approval of the Board:of Health) broken pipe(s)are replaced obstruction is removed - distribution box is-leveled or replaced _The system required pumping more than four times a year due to broken or-obstructed pipe(s). The system will pass inspection if(with,approval of the Board of Health): - "' broken pipe(s)are replaced`, obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE,BOARD OF HEALTH: Conditions,exist which require further evaluation by.the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE-SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. Tl a system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well: The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution.for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 0]. SYSTEM FAILS: y I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. II (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 Rolling iiftch Rd.Centerv0le Owner: Freeman:1204 Greendale Ave.Unit B 9 Needham,Ma.02192 Date of Inspection:8121196 D]SYSTEM FAILS(continued) _ 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 1l2 day flow. - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. _ Any portion of a'cesspool or privy is within a Zone 1 of a public well. Ariy portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable.water quality analysis. if the well has been analyzed to be acceptable, attach copy of well water analysis for li coliform,bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The.following criteria apply to large systems in addition to the criteria: The system serves a facility With a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water supply well) the owner or operator of such system shall bring the system and facility into full compliance with the groundwater treatment program p any requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department-for further information. (revised 11115195) 3 r 51 . 1 9111M - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST - Property Address: 197 Rolling Hitch Rd.centervoe _ Owner: FreemanA204 Greendale Ave.Unit B 9 Needham,Ma.02192 Date of Inspection:9121/96 Check if the following have been done: - - X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least two weeks.and the and the system has been receiving normal flow rates during that_penod. Large volumes of water have not been introduced'into the system recently or as part of this inspection. GaAs built.plans have been.obtained and examined: Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive nary-sanitary or industrial waste flow.. X The site was inspected for signs of breakout: X 'All system components, excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for.condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants.if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 197 RaII1ng Hitch Rd Ces�erv0le - Owner; Freeman:1204 Greendaie Ave.Unit 8 9 Needham,Ma.02192 Date of Inspection:8121/96 - FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons -- Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): Yes_ - Laundry.connected to system(yes or no): Yes. _ Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: ► COMMERCIAL/INDUSTRIAL Type of establishment: Na Design flow:0 gallons/day Grease trap present:(yes orno) No Industrial Waste.Holding Tank present:(yes or no) No Non-sanitary waste.discharged to the.Title 5 system:.(yes or no) No Water meter readings, if available' nla Last date of occupancy: n/a OTHER: (Describe) nla Last.date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection:(yes or no)No If yes, volume pumped: 0 aallons Reason for pumping; n!a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1974 Sewage odors detected when arriving at the site:{yes or no) No (revised 11115195) ,. 5 t•j"� 11 E R :. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - - SYSTEM INFORMATION(continued) Property.Address: 197 Rolling Hatch Rd.Cerdervllle - Owner. Freeman:1204 Greendale Ave.Unit 8 9 Needham Ma .02192 - Date.of Inspectio-n:8121/96 _ SEPTIC TANK: X.. _ (locate on site planj _. Depth below grade 16?' - Material of construction:X concreate- metal'. FRP other(explain) Dimensions: L8'6'h5'7'W4'10" - - Sludge depth:4' Distance from top of sludge to bottom of outlet tee or baffle: 23' Scum thickness U Distance from top of-scum-to top of outlet tee or-baffle,6' Distance form.bottotn:of scum to bottom of outlet tee or baffle: u _ I Comments: ' (recommendation for,pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage)'!etc.) . Septic system and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP; - (locate on site plan) Depth below grade Na Material of construction: _concrete metal- FRP_other(explain) Dimensions: n1a Scum thickness:rva Distance from top of'scum to top of outlet tee or baffle:.rda Distance from bottom of scum to bottom of outlet tee or baffle: ma Comments: (recommendation for pumping,,condition of"inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) Na (revised 1 ill 5/95) g iT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued), Property Address: 197 Rolling Hitch Rd.Centerville Owner: Freeman:1204 GreendaleAve.UnitS 9 Needham,-Ma.02192 - Date of Inspection:8121196 — TIGHT OR HOLDING TANK: (locate on site plan) - Depth below grade: Na Material of construction: -concrete—metal: FRP_other(explain) - Dimensions: Na . Capacity: n/a gallons - Design flow: Na gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm aridnoat switches,etc`) Na DISTRIBUTION BOX.- (locate on site plan) Depth of liquid level above outlet invert: nta Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box eta) Na.. i PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition 0i pumps and appurtenances, etc.) _Na y (revised 11115195) _ 7 v =, su --- SUBSURFACE'SEWAGE DISPOSAL SYSTEM.INSPECTION FORM _ PART C _ - SYSTEM INFORMATION(continued). Property Address: 197 Rolling Hitch Rd.Centerville Owner: Freeman:1204,G_reendwe Ave.Unit B 9 Needham;Ma.02192 Date of inspection:.8121196 _ SOIL ABSORPTION SYSTEM (SAS):X (locate on.site plan,,if possible; excavation not'required, but-may be approximated by non-intrusive methods) ' If not determined to.be present, explain: n/a Type: - leaching pits, number: 1,000 gallon leach pit leaching chambers;number:3-inflowtrators leaching galleries, number n1a leachingienches;.number,length: n/a leaching fields, number, dimensions:n/a overflow cesspool, number`n1a Comments:(note condition of soil, signs of hydraulic failure; levei of ponding, condition of vegetation, etc.) The the leach it had 3.of water in it at the time of the ins ctioh.It is structurali sound and functioning property.The inBawtrators.are stucutralfy sound and Functioning properly P by CESSPOOLS: (locate on site plan) Number and configuration: n/a Depth-top of liquid to;nietinvert: n1a Depth of solids layer;` Na Depth of scum layer: n/a . Dimensions of cesspool: nra Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool m Na ust be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failu n/a re, level of pond ing,condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: n1a Depth of solids: n1a Dimensions: n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PrivyComments I _ . (revised 11/15195) r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOId�FORM v,r PART C SYSTEM INFORMATION(continued) _ Property Address. 197 Rolling Hitch.ft Centerville i -- Owner: -. -- FFeeman:1204 GreendWAve.UnB-B 9 Needham,Ma 02192 - Date of Inspection:8121198 SKETCH OF SEWAGE DISPOSAL SYSTEM: - t- include ties to at least two.permanent references landmarks or benchmarks locate all wells within 100AA W o a _ AE 0 b �' D 30 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: k USGS Maps and Charts E I (revised 11115195) 9 . i CERTIFIED SEPTIC SYSTEM REPORT Nov P, LOCATION � � � 197 ROLLING HITCH RD . CENTERVILLE, MA 02632 MAP 192 PARCEL 099 LOT 47 PREPARED FOR SELLER MR . ROBERT BURWICK & MS . BARBARA CARLIN 435 MAIN ST . NORWELL, MA 02061 BUYER MR. JOHN HAMBLY & MR. JOHN STRAllULLA 197 ROLLING HITCH RD . CENTERVILLE, MA 02632 PREPARED BY HILLIARD HILLER P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 i. i Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WIIIIam F.Weld Gorma Trudy Coxe t»a.t. ,EOEA David S. Struhs CommMioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 112 Address of Owner: y,35- "IA,; 51-, Date of Inspection: //1 a� (If different) Name of Inspector: �"�� Company Name, Address and Telephone Number: /ztg BoX ;)Sv CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: TKe System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving au;horit). INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: �I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. Bj SYSTEM CONDITIONALLY PASSES: ., One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 6/15/95) One Winter Street a Boston,Massachusetts 02108 is FAX(617)556-1049 is Telephone(617)292-5500 A " Printed on Regcied Papa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 197 RoGU�G Ro Owner: MR 45--O° Date of Inspection: //�G e 1111119,— B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The cvctem has a septic tank and soil absorption system and is within 100 feet to a surface water supply of tiibuidry to a surface water supply. The systen, has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The sysien, hip a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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 (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: &-2 -4 Owner: ^re, BoB Date of Inspection: /11--A;5- DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatmesrt program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1172 A//Te% Il0 'e Owner: `✓&-'e Date of Inspection: Check if the following have been done: vPumping information was requested of the owner, occupant, and Board of Health. ZZ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or a5 part of this inspection. .�As built plans have been obtained and examined. Note if they are not available with N/A. .:—The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non-sanitary or industrial waste flow vThe site was inspected for signs of breakout. ✓AII system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees material of construction dimensions depth of liquid, depth of sludge, depth of scum. P q P g P } ✓rhe size and location of the Soil Absorption System on the site has been determined based on existing information or F approximated by non-intrusive methods. vThe facility o,%ner (a- occupants, if different, 'rorn owner? were provided with information on the proper maintenance of Sub- Surface Disposal System. '(revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 112 iQoLG/vG //irc// /?o c Owner: ,r- *r s9p%5. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: . gallons Number of bedrooms:_, Number of current residents: .1 Garbage grinder (yes or no):•�S Laundry connected to system (yes or no):7% Seasonal use (yes or no): Water meter readings, if available: /rr'"s" - /GC r Last date of occupancy: A 4—.,/1-y COMMERCIAUINDUSTRIAL- Type of establishment: Design flow: aallons/day 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: .OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_J,,4;p If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM _ L,," _ Septic tan soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) i APPROXIMATE AGE of all components, date installed (if known) and source of information: iNl /crllAia?s /90� � v.�oa( i°t.c�ir is- 4�;;Z Sewage odors detected when arriving at the site: (yes or no)� tzevised.8/15/95) 5 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: /97 ,QoGGivG fiTGif �?Q GC.�i;'iZv/ct! , W-1,4 Owner: /ii/ 906 d�J?tv/off t5 PfS. !3/�.�l�fl.�� GRi?G1.v Date of Inspection: SEPTIC TANK: 4,-" (locate on site plan) Depth below grade: /7 Material of construction: ✓concrete _metal _FRP—other(explain) Dimensions: Sludge depth: L 7"' Distance from top of sludge to bottom of outlet tee or baffle: Pj'7? Scum thickness: C;, Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. ?A,ul� o tS L 4a2`'�'D GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scut thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom ni 5rom t- bonom of ou!!et tee or banie: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised.8/15/95) 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /97 �Pot.�ivG' lf�TG/ i+°� GA9.�Tlit L/!44 Owner: .07of /�/•a'�'� !'JS �iva� G/9�Liv Date of Inspection: /1Aa G TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP other(explain) Dimensions: Capacity: gallons Design floes`: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and d:strib:aicr. cq �!, c.idcrce of so!ids carr\,over, evidence of leakage into or out of box, etc)- PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) ' (revised 8/15/95) 7 f. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f%2 /?o ivG /fiTG// Q/J -Cx.'a Owner: *.e. X?.Ad .tom'We4/rc PY b /•rS. /�/trs �ti f� :✓�l' �,v Date of Inspection: /�i��9 S 6 SOIL ABSORPTION SYSTEM (SAS):tv (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching c-laaAx6tzs, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) '/r SG✓.►* y 1' 1?/,•'e _ -FH,C.?C /S 1 ?44 Z�cir CESSPOOLS: � (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 (cesspool must be pumped as part of inspection) 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.) tzevised 8115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /97 /0ra ll /PG Owner. iy/?. (�U/Il��� i`/S. /.3i9�Bffi'y G/9/1Li.v Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' G/< Oj f/U%SE Y c; I DEPTH TO GROUNDWATER Depth to groundwater: ?V 7" feet method of determination or approximation: 60"Ioe5,1-�IY41z' r�/S 7a: 7N� b/�L%IUhJ t�✓s?ii/1 T/Y��lef Ty,UK /4��,��' D.(�i9wiyrr Sirs 7-11 Tff,3G1f /1T LiATo�r/ 3G', 7/ ,d,T C✓�9s 8'�o" OCR !3/�ow G�,4DL 7/ (revised 6/15/95) 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. Cityrrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The.system: p ® Passes El Conditionally Passes ❑ Fail 9q J ""+ a ❑ Needs Further Evaluation by the Local Approving Authority N `^ Zdlz r.� i 10/09/2009 Inspector's Signa ur Date 4. rn The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 P 9 P Y 9 t l Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 } t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•''r 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every 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•09/08 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is Centerville required for Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon tank,one leaching pit and three infiltrators. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected?- ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2008:8,0000 9 ( Y 9 (gP ))� 2008:8,000 Detail: 2007:27gpd 2008:22gpd Sump pump? ❑ Yes ® No Last date of occupancy: 10/9/2009 Date Commercial/Industrial 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: new leaching installed 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' 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: 1000 gallon Sludge depth: 2e t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc:): Pump septic tank every two tears.Inlet and outlet tees are in place.No evidence of leakage.tank appears structurally sound. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I` Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No D-Box Present. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ® leaching chambers number: 3 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line up to overflow invert.Infiltrators were dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately Qa�X j I I i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 50'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 197 Rolling Hitch Property Address John Freeman Owner Owner's Name information is required for Centerville Ma. 02632 10/09/2009 every 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 7 TOWN OF BARNSTABLE 7y_ 3a� LOCATION /1? 2r 1-41/,6,6 /{ice.% SEWAGE # Cia - 91,;,- VILLAGE ASSESSOR'S MAP & LOT / LT 5'7 INSTALLER'S NAME&PHONE NO. 11XG,—, �Y CG• j SEPTIC TANK CAPACITY / mil LEACHING FACILITY: (type) /f/% 3 �1r NO.OF BEDROOMS .3 FOR OWNER A X Alc 9W .�ie4,,- — -42-5 PERMTTDATE: 9-2-5z COMPLIANCE DATE: Separation Distance Between the: i Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 0?Z/ 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 leachingfjcility) Feet Furnished by A /� �•:�;.. -- Q 6�'c/� ' �G` ' 4 4 ./ �I TOWN OF BARNSTABLE .� ►>y- �2 i LOCATION(__y- y-7 (Q'? 12Auwj,- w-%et1 M SEWAGE # VILLAGE C CYSC��V1`I� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. jAk&i:`k CbaOs� SEPTIC TANK CAPACITY 14. 000 LEACHING FACILITY:(type) NO. OF BEDROOMS3 PRIVATE WELL R PUBLIC WATER _ BUILDER O OWNE DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: z/oZ VARIANCE GRANTED: Yes No L i ,. F _ Location:— Lot ; 47_Aolling_Hitth Rd. Sew. _Permitk325_ Village: -Cent-ervtll - Installers- Frank J. L-innar-es -- -- -- - -- -P.C._ Box 661 - Mattapoisett_,__Niass. -Builders-- -William E.- DaceyI-Jro - - - - _ _ -- -- 112_West_Main_St. _ Hyannis, Mass. _ __Date -Permit _Issued s // .f 7y/ - -- Date Compliance Issued: `. -= .. �� ' __ �► i � �, . + 1 ............... THE COMMONWEALTH OF MASSACHUS TTS BOARD HEAL _ . .-. .. ...... ... OF................................. Application is hereby made for a Pe mit to Construct ( or 4Reair ) an Indvdidual Sewage Dis sal System at • .................. %'/�� �f� Location-Add ess or Lot NoA� O ner Address W Installer Address � P� l U Type of Building �`� Size Lot----- � .�''�Sq. feet Dwelling—No. of Bedrooms--...---.... _________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) OtherW fix s ----------------------•--•--------•---------------•-- -----------------------' ---------------- ---------- Design Flow___________ __ .........................gallons�pe�r/person per day..,Total daily flow------------- WSeptic Tank—Liquid'cahacl ygth................ Width---------------- Diameter__.-------____-- Depth---------------- x Disposal Trench—N_o_________ Wii____ --------- Length----------------- To' Pleaching area----- ft. Seepage Pit No_________________ _ i al leaching area---------------__sq. ft. z Other Distribution box ( ) osing tank ( ) �-' Percolation Test Results Performed by-------------------------------------------------------------------------- Date--•--•--------------------------------- Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water...___-_-___-_--_-__._. fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------- epth to ground water_-._.._________-________ --- •------•---------••----------- --- ----------------------------------------------------------- e-of Soil •-----. --- U --•---•--------•---- ---- ------............. --••-• - ------------------------------------------------------------------------------ W x ----------------------------------- ---------------------------------------------•--------------- 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 Article XI of the State Sanitary Code— The undersigned fV#1er agrees not to place the,system in operation until a Certificate of Compliance has een iss ed y e board of a h. it Signe ---- ------ Application Approved BY ................Z. ••-- t --" 1 / Date Application Disapproved for the following reasons-------------------------- ------------------------------------------------------------------------------ Da t e PermitNo......................................................... Issued..... _ _.� ................... -- f 1,2 No..........k. ............ ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 P HLi A L ..... OF...................................... . ............................. ............ Appliration -for Uhipoiial Workii T triartion Punfit Application js.hereby made for a P rmit to Construct or Re air osal System at: ............................................. ...... .. .. ......... ........... .................................................................. Location-Ad 77 or Lot No. ............................ ................... ................................................................................................. ------ Owner Address ........... ................................................................................................... Installer Address Type of Building Size Lot_... __. ____"__ Uq. feet Dwelling—No. of Bedrooms----_____----3--------------------------Expansion Attic Garbage Grinder PL4 Other—Type of Building --------................... No. of pei-sons_-------------------------- Showers Cafeteria' Otherfi S ----------------------------I---------------------_------------------------------- 11 -------------------------- Design Flow..............YVI ------.......................gallons per erson per day. Total daily flow-___ ----------------- ----gallons. r4 Septic Tank—Liquid capa s�Zgth---------------- Width...__.-....._.. Diameter__-.--_-------- Depth---------------- cKonallo Disposal Trench—No. ...... ..............Wi h...... -----------Aotal Length--*------------- Tqr4.leachingarca----- ft. Seepage Pit No................. ...... . . ...... tal leaching are- ----------------sq. ft. Z Other Distribution box osing tank Percolation Test Results Performed by.......................................................................... Date--_-----------------------.------------- Test Pit No. 1.................minutes per inch . Depth of Test Pit....._..____.____... Depth to ground water------------------------ Test Pit No. 2...... .........minutes per inch Depth of Test Pit._____.__..______.__Aepth to ground water............... -------- ....... .................................................I... ...I---------------------------------------------------------- 0 Description of Soil-------------_- ............. ..... ...... ---------------------------- ------------------------------------------------------............ U -------------- -----I--_----------- ... ........................... ................... . ....... ... ...............................7------------------------------------------------------- ---------------I---------------- ----------------------------------------- ........... -------- -------------------------------------------------------------------------------------------------------- U _Nature re.of R epairs.or-Alterations—Answer when applicable------------------------------------------------------------------------------ ................. ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- N Agreement:. ------------------------------------------------ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Aftitle XI of the*State Sanitary Code— The underslgynZie'd-f rther agrees of to place the system in of 'ea;l operation until. a Certificate of Compliance has been isstftr e board of th. . .. . .................................................. .... .. .... Si ...... I, to. . 1 7 .Z ............... ....... ........................... . .... ........ Application Approved By-----I----------------------- .... ... .......V_`_ Date Application Disapproved for the following reasons-:.............................................................................................................. .......................................................................................................................................................................... ----------------------...... / 11� Date Permit No. ............................ Issued •....... ...... ...... 7------------- E COMMONWEALTH OF MASSACHUSETTS BOARR/,�6F HEAL ....... .............,4...................O rK...... .. .. ............... .. ..... .... ................................ TkIertifiratr of Tomptiaurr T11IS,IS r-F constructed (._<®r S e�5 trI Y, That Ae IndLvVall Sew�eDis osal System constri. Repaired by-----:......................... ......... - --------- --------------- *....... .2. ...................��2 ------ 'e�t.L- ---------- ns ler at................ -------------- .. le Xi e State Sanitary Code as described in the has been installed in accordance the pr visions 0 r application for Disposal Works Construction Permit N 0..........!.... .......... .......... date ---------------- THE ISSUANCE OF THIT CERTIFICATE SHALL NOT BE CONSFTK!VEDAS U RANTEE THAT THE > ------------------- S SYSTEW WI FVNCT,ION RY. . ........ DATE............. ------1 .77 Inspector............ -------- . ... ................................................... -------- ---- THE COMMONWEALTH OF MASSACHUSETTS BOA7R 6F HE L V, 0 F........... ................✓................................................. No.......... ............. FEE.... ................ 0 onfit , ,t tall Prrmit Permission is ereby granted.......t- ---------- -- ------------ ----- .1-- ------- ------------- air r Rylp to Construct an Ind'- -. al/ age! D y(osal ys at No.----------------- is - ---- ------------------------------------- --------- -- Street as shown on the application Construction cation for Disposal Works Constru P t No. Datril-44e -----------V- ----- ------ 0- �•. . ... ......... 11 ... --- ................ Board of Health ....................................... FORM S & WARREN. INC.. PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA d 1 f`,! 16 �. , n { i 7— r //Iartt.-4 1'� ` r�•/�• x �,ix• CERTIFIED PLOT PLAN LOCATION t �:K,y � ..,.,,,.•r SCALE . . / DATE ✓.' � ; PLAN REFERENCE . S,Lr(`��) �J:i►L I .E.Y')'2„ /'1`. J��. .��,'(U/�. '!��t/�.1�Tl, �� _ V'_�� •� •r1.. � ia•7,Y g_r.;.,4. ,'t�l,7`i(.) 1?fi 1`�'C. 1.�'. y(r"t' �1 !�l'. f'+1.�'. 1. .� ... �r �`iI^ .r`_..r, j ran+rI'H, iMA 4,41 ttw J, S% f:'.� sue. ' .'':•`;<'.i'" /4'..V f CERTIFY THAT iriC SHOWN ON THIS PLAN IS LOCATED ON THF GROUND AS SHOWN HEREON AND THAT IT CONFORMS YO f '�="'r�% �`;.,':s: 1�.via THE ZONING LAWS OF 'TNE TOWN Or 7 w r" fI).f;/,!/ _.. 'jr'._ — � ./,: .. . . . . . WHEN I /-i)1;4AlIv/ DATE JL f`' T it ;C/id► t7 . REG. LAND SO LVE`:OR