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HomeMy WebLinkAbout0031 SOUTH MAIN STREET - Health (2) 31 SOUTH MAIN STREET_ CENTERVILLE A = 228 118 ! 6 6 I UPC 12534 No.2 Woo HASTINGS..MN Jun 2715 07:18p p.18 "0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 South Main Street Property Address ` Kevin Mitchell Owner Owner's Name information is required for every Centerville ✓ MA 02632 6-24-15 page. Cityrrown State Zip Code Date of Inspection �x 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.Importa . fling Out forms when A. General Information on thecomputer, �lyy�,�wJ tH OF'.4gS use only the tab 6/ I� " " .�ya ,9 spa•,.... S+ �v 1. Inspector: -� ..�y key to move your cursor-do not JamesD.Sears JAMES m use the return key. Name of Inspector = CapewideEnterprises,LLC r6. Company Name 153 Commercial Street '�����rh Ifr�SEpEG\���e Company.Address Mashpee Ma ___----- __ 02649 Citylrown State Zip Code 508-477-8877 S 162 3 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 arld complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ 'Needs Further Evaluation by the Local Approving Authority 6-24-15 spectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "*""This report only describes conditions at the time of inspection and under the conditions of use at that time-This inspection does not address how the system wiif perform in the future under the same or different conditions of use. t) Uns•3113 Title 5 Official Inspection Foam:Subsurface Sewage Disposal Syslem•Page Id 17 Jun 2715 07:19p p.19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owners Name information is CerttelviNe required for every MA 02632 6-24-15 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 system is a 1500 Gal. Tank D Box and two dry well chambers. 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 o)d*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•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Jun 2715 07:19p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is Centervide MA 02632 6-24-15 required for every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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): I r ❑ 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 satt marsh t5ins-W Title 5 Official Inspection Farm*Subsurface Sewage Disposal System-Page 3 of 97 Jun 2715 07:19p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is Centerville MA 02632 6-24-15 required for every ' page. cityfrown State Zip Code Date 0 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 f Y P e 1 o a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water a supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 Feet but 50 fleet 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 tess 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 0 Discharge or ponding of effluent t 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 ausapemill is less than 6" below invert or available volume is less than Yz day flow t5ins•V13 Title 5 Official Inspedion Forth:Subwdace Sewage Disposal System.Page 4 of 17 Jun 2715 07:20p p.22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information Is required for every Centerville MA 02632 6-24-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year AfOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ z 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. 1 ❑ ® 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 CMfR 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 farge 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 I I 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•3113 Tine 5 Official Inspection Form:SOSUrfaca Sewage Disposal System•Page 5 of 17 Jun 2715 07:21 p p.23 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owners Name information required for every Centerville MA 02632 6-24-15 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the 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)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 isms•3113 rule 5 oKtlel In spection Form:Subsurface Sewage Disposal System•Page 6 of 17 1 Jun 2715 07:21 p p.24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information required for every Centerville AAA 02632 6-24-15 page. City/Town State Zip Code Date of inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and two dry well chamber's.' x Number of current residents: 1 Does residence have a garbage grinder? C] Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system Inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2013-22,00 ais 2014-23,000GalaI's Detail Sump pump? ❑ Yes ® No Last date of occupancy_ Present Date CommerciallIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons par 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•3M3 Title 5 Orridal Inspection Form:Subsurface Sewage Disposal System-Page 7 or 17 F Jun 2715 07:22p p.2.5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information required for every Centerville MA ,02632 6-24-15 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: t Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe). t5ins•3113 7RIe 5 Official tnspection Foam:Subsurface Sewage Disposal System•Page 8 of 17 Jun 2715 07:22p p.26 Commonweafth of Massachusetts Title 5 Official l Inspection Farm - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name required for is Centerville MA 02632 6-24-15 required for 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: 2001 Permit # 2001 - 485. Were sewage odors detected when arriving at the site? ❑ Yes 1Z No Building Sewer(locate on site plan): i Depth below grade: 34"feet Material of construction: []cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 22"feel Material of construction: i ®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: 1500 Gal_ Precast H-10 Sludge depth: 2 t5ins•V S Title 5 Official Inspection Fwm:Subsurface Sewage Disposal System•Page 9 of 17 I- Jun 2715 07:22p p.27 Commonwealth of Massachusetts Title 5 Official Inspection Form R' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name Information is required forevery Centerv_iNe __ __ MA 02632 6-24-15 e page. corrown State Zip Code Date of Inspection D. System Information (cons.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0" 8e Distance from tap of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbr'.rilt-Tape _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.): Tank at working level. Tank and inlet cover at 22" below grade wlout let cover at 4". In and out let tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: -.--- Date t5ins•3!13 Tele 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 10 of 17 Jun 2715 07:23p p.28 Commonwealth of Massachusetts -- Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is required for every Centerville MA 02632 6-24-15 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: pate Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No (Sins•3113 Title 5 Official fnspedon Form:Subsurface Sewage Disposal System•Pape 11 of 17 Jun 2715 07:23p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information required for every CentervOte MA 02632 6-24-15 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 0 — Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"x`l6"-33" below grade. Sox is clean and solid wlone tine out. No sign of over loading or solid carry over. i i i i l Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t51ns•3M 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 i Jun 2715 07:23p p:30 Commonwealth of Massachusetts Title 5 Official Inspection Form .I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is Centerville MA 02632 6-24-15 required For every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number 2 ❑ 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.): Leaching is two 500 Gal. dry well chamber's 26xi3'. Chamber's are 42" below grade w16"water_ No sign of over loading or solid carry over. No high stain line. 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 rains.ar a Tiue 5 official Inspection Form:Subsurface Sewage Dispasal system•Page 13 or 17 Jun 2715 07:23p p.31 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurrace Sewage Disposal System Form- Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is required for every Centerville MA 02632 6-24-15 page. Cityfrown state Zip Code Date of Inspection D. System Information (coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I Privy(locate on site plan): 1 Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): sins-3/i3 Title 5 official Inspection Form:subsurface Sewage Disposal System•Page 14 at 17 Jun 2715 07:24p p•32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owners Name information required for every Centerville MA 02632 6-24-15 page_ CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A-/=37`' =38' A-� s=30 N-3 -3:y� 8 C i p Ot 3 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Jun 2715 07:24p p.33 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information is required for every Centerville MA 02632 6-24-15 --_--.— page. Cityrrown State Zip Code Date 0lnspectlon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar C ❑ Shallow wells Na 10 Estimated depth td�lgh ground water. 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 propertylobservation 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: Auger T.H. 10' No G.W.. Bottom of chambers at 4'-6"below grade. Bottom of chambers at 5'-6" above T.H.. Before filing this Inspection Report,please see Report Completeness Checklist on next page. f5ins•3f13 Tito 5 OfMde!Inspection Form Subsurface%wageDispo3a0 System•Page 113 or 17 Jun 2715 07:24p p.34 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 South Main Street Property Address Kevin Mitchell Owner Owner's Name information required for every Centerville MA 02632 6-24-15 page. City(rown 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 Applicabie,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 i i 1 5 t5ins•af13 Title 5 Official inspection Form:Subsurface Sewage Disposes system•Page 17 of 17 Commonwealth of Massachusetts -� : Title 5 Official Inspection Form R Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611612000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 31 South Main St. only the tab key Property Address to move your Hayes cursor-do not Owners Name use the return key. saa Aw---h Owner's Address Centerville MA 02632 City/Town State Zip Code I I Date of Inspection: 5/9/06 Date 2. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd. Company Address Mashpee MA 02649 City/Town State * Zip Code4_ 508.272.6433 _ Telephone Number T n. Certification Statement: 1 certify that I have personally inspected the sewage disposal system at this address and that they information reported below is true, accurate and complete as of the time of the in pection-.�j he inspection r was performed based on my training and experience in the proper function and aintenance of o.,n site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Ne7�= by the Local Approving Authority 5/9/06 Inspector's Si§nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 31 South Main St Property Address Centerville MA 02632 Cityrrown State Zip Code Hayes 5/9/06 Owner's Name Date of Inspection 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System y � Commonwealth of Massachusetts ! Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form A. Certification (cont.) 31 South Main St. Property Address Centerville MA 02632 Cityrrown State Zip Code Hayes 5/9/06 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts a Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) 31 South Main St. Property Address Centerville MA 02632 Cityrrown state Zip Code Hayes 5/9/06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(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 Y P more from a private water supply well". Method used to determine distance: n/a **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: Title 5Template.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 31 South Main St. Property Address Centerville MA 02632 Cityrrown State ZipCode Hayes 5/9/06 Owner's Name Date of Inspection 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 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.] Yes 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 31 South Main St. Property Address Centerville CitylTown State Zip Code Owners Name Date of Inspection 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 31 South Main St. Property Address Centerville Citylrown State Zip Code Owner's Name Date of Inspection 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(3)(b)] Title 5Template.doc•11/2004 Title 6 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M C. System Information 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms.(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330GPD Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: n/a gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system _ ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and'source of information: New system 2001 per BOH file Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): no adverse conditions exist Septic Tank(locate on site plan): Depth below grade: 116"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: n/a years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1500g Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2' Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M , C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owners Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is reccomended every other year to prolong_ the life of the system. No adverse conditions exist at this time Grease Trap(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: n/a 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: n/a Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cunt.) Dimensions: n/a 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.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Liquid is level with the bottom of the pipe Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is 2'6 below grade. No adverse conditions exist. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection 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: Type: ❑ leaching pits number: ® leaching chambers number: _ 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No adverse conditions exist at this time. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration n/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No ' Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: n/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 31 South Main St. Property Address Centerville Cityrrown State Zip Code Owner's Name Date of Inspection 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. =00 O oc_ � A l� Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System i z� Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 31 South Main St. Property Address Centerville City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: Ground water mappping puts ground water at>20' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 5��-- 9 4 71 :VI :WAGE PERMIT NO. LAGE A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED '7V -CA vi 1 �In Q COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 31 S Main St. Centerville Owner's Name: Chuck Richardson Owner's Address: 180 Main St_ Andoypr, MA Date of Inspection: D/ Name of Inspector: (please print) William E_ • Robbinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 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 S on 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: , Date: 2 C5 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 l ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 S Main St. Centerville Owner: Richardson Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy tem 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. mments: A B. yytem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expl in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally un ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the e sting tank is replaced with a complying septic tank as approved by the Board of Health. * metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance dicating that the tank is less than 20 years old is available. D explain: Observation of sewage backup or break out or hi static water level in the distribution box due to-broken or g P f� ob tructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled.or replaced explain: The system required pumping more than 4 tines a year due to broken or obstructed pipe(s).The system will p s inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 S Main St.- Centerville Owner: Richardson , Date of Inspection: —U 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 fail' g to protect public health,safety or the environment. 1. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the ystem 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. c yytem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syst m 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: 31 S Main St. Centerville Owner: Richa dson Date of Inspection: —0 D. System Failure Criteria applicable to all systems:. Youl must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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 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.] ( es/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. Larg Systems: To be con idered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must' dicate either"yes"or"no"to each of the following: (The follo ing criteria apply to large systems in addition to the criteria above) yes no e system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(I.nterim Wellhead Protection Area—IWPA)or a mapped one II of a public water supply well If you hav answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in S tion D above the large system eras failed.The owner ar operator of arty large system considered a significant hreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.Th system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 31 S. Main St. Centerville Owner: Richardson Date of Inspection: 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? t/ 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: Yes 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 S Main St. Centerville Owner: Richardson Date of Inspection: `6 FLOW CONDITIONS RESIDENTIAL 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):1 Number of current residents: b Does residence have a garbage grinder(yes or no): g' Is laundry on a separate sewage system(yes or no): &aif yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): lkX Water meter readings, if available(last 2 years usage(gpd)): 2()0() 99, 000 gal. Sump pump(yes or no): /&-v 1999 122,000 gal. Last date of occupancy: ,_ CO ERCIAL/INDUSTRIAL Type o establishment: Design ow(based on 310 CMR 15.203): gpd Basis o design flow(seats/persons/sqft,etc.): Grease ap present(yes or no):_ Industr al waste holding tank present(yes or no): Non-s itary waste discharged to the Title 5 system(yes or no): Water eter readings,if available: Last to of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ld.� Was system pumped as padof the inspection(yes or no): )L g If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TY.P OF SYSTEM _l/Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 410 Were sewage odors detected when arriving at the site(yes or no):!�/c) 6 r Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 S Main St_ Centerville Owner: Richardson Date of Inspection: / ~ v J B LDING SEWER(locate on site plan) De th below grade: M erials of construction:_cast iron _40 PVC_other(explain): Di nce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:"(locate on site plan) l � Depth below grade: l 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: G b Sludge depth: C Distance from top of sludge to bottom of outlet tee or baffle: _ - Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffler a/ How were dimensions determined: /ji !r-tw !✓•� 1/� 'Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.lea age,etc.): GR SE TRAP:_(locate on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_fiberglass_polyethylene_other (expla' ): Dime ions: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: Dat of last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as lated to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 S Main St. Centerville Owner: Richardson Date of Inspection: / 6 � TI T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mater al of construction: concrete metal fiberglass_polyethylene other(explain): Dime ions: Capac gallons Design Flow: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Co ents(condition of alarm and float switches, etc.): V opened)(locate on site plan) DISTRIBUTION BOX. (if present must be open )( p ) Depth of liquid level above outlet invert: e 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.): PUM CHAMBER: (locate on site plan) Pump in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 S Main St_ Centerville Owner: on Date of Inspection: SOIL ABSORPTION SYSTEM(SAS)::7(10cate on site plan,excavation not required) If SAS not located explain why: Typ�Ieaching ,�1 pits,number:_V ching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative"system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): c _ 41 b v CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet iil�:W 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) Materi s of construction: Dimen ions: Depth f solids: Comm nts(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: 31 S Main St. Centerville Owner: Richardson Date of Inspection: —25"0 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. r 1 ti 4 � ' r J 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 S Main St. Centerville Owner: Richardson Date of Inspection: 51" "01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 1L b feet Please indicate(check)all methods used to determine the high ground water elevation: btained from system design plans on record-If checked,date of design plan reviewed: bserved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: me3 Checked with local excavators,installers-(attach doc entation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: l3a k D S 21'-1 1D,5 x d 11 tr- TOWN OF BARNSTABLE '�.,&A7� R' � ; S a v�� ��ea i�t 5$ , SEWAGE # _�D�`_ '4�'b5� 'PILLAGE V F C's k t ASSESSOR'S MAP & LOT?2 3'-Ile INSTALLER'S NAME&PHONE NO. ca ►..� ��ry�_ Si �'1FT(� SFPTIC TANK CAPACITY _ A S o c3 LEACHING FACILITY: (type) _ Dry IQ r (size) NO.OF BEDROOMS BUILDER OR OWNER 'p/'�', PERMTTDATE: COMPLIANCE DATE: r . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 ching f ility �. Feet Furnished by___�� 1 M� r 1 b\ No. ��!'r T � Fee$5 n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mi!5poga1 *pftem Construction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 31 S Main St. , Centerville Chuck Richardson Assessor'sMap/Parcel 180 Main St. Andover MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system (-_r)ns i s— ting of a 1 ,500 gal. tank, D-box and 2 precast leach chambers with stone all around. Date last inspected: i. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oar f Health. Sign .. ce Date 6 Application Approved by Date Application Disapproved&1K following rea Permit No. 640 Date Issued No.� li!/�"' Fee S S 0 Iv ter'THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTHes xiIVISION - TOWN Of BARNSTABLE, MASSACHUSETTS� Y� ZIpprtcatton for �Digooar 6p5tem Congtructton Vermtt Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components`, Location Address or Lot No. Owner's Name,Address and Tel.No. 31 Si Main St.,, Centerville Chuck Richarddon Assessor's'Map/Parcel Z Z� _ 11r 180 Main St. , Andover, MA Installer's Name,Address,and Tel.No. �! Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service I' O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system consis— ting of a 1 ,500 gal. tank, .D-box and 2 precast leach chambers with stone all around. Date last inspected: Agreement: ,. . The undersigned agrees to ensure the construction and maintenande of the afore described on-site sewage disposal system y in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Roard4f Health.Sign � t c n Date 6'7R-/F—dy Application Approved by � >?'1 Date Application Disapproved for the following reason V / . e5.& �-'' � Date Issued Permit No. ----------------------- ------r v ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Richardson Certtftcate of•compliame THIS IS TO CERTIFY, that the On-site Sewage'Disposal System Constructed( ).Repaired( X)Upgraded( ) Abandoned( )by Wm. , E. Robinson Septic Service at 31 S Main St. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe r W9:: — � dated `ZY" Z- C> f Installer Wm. E. Robinson Sr. Designer The issuance of this permit shall not be construed as a guarantee that the ���nedDate , . Inspect t a N...7drl, �WZ57�r Fee $50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Richardson 't6pooaf *proem Conotructton Vermtt Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 31 S Main St. , Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must b ccoom leted within three years of the date oft rmii. Date: (/t 1./ Approved b f PP Y v l >. ''� 1lLf99 - NOTICE_This Foam Is To Be Used For the Repair Of Failed , Septic Systems Only- c'BTrrntic i.-IYON oP S w>+m aP>e�sCA'riOK VOR A DISroSp.L WORKS CONSTRUCTION Iff(WITHOUT DESIGNED PLANSi h William E_ Robins ori,S y ceaffy mast the application Ix comau uou penm 4wimed by me dared —��� t1', ,commming the, property located at 31 S Main St. , Centery i i 1 e meets an of the following criteria • The systtM is amacmd m a mademd dwdbng ady Theft ate no commmcmi or business Usm wish toe dweUiu& TIM •t is c1mmi d as CLPaS l and the pervaudan tame is tem mcm.w cquw io 5 numaua per inch There c no wetlands wid"100 feet of the pngmsw sc pac k-tscm — TIICR GO ptivatc wdb wdbm 00 Poet of�ps gmmd sCpac sysmi There i-an mmast in ftw m�t in uvc pmpowd • There no variances necprested ar needed - The of d P g wit[am&be iaewed lass than five�,ba�e tha ,,Iron ratite etevadw IA4M*a Wm adwacr mWs using the Fnmpror mcdwd when appficabicl 1f the a A-S.wiB be locand with 250 foa of aW vegetated wcdaeft.Wk bm m of We proposed lrwhmg bcdkY wiU lobe Located teas d um fautacu t 14)fact above dw m mmum add tabk Phmr cmmpftm tle MwmW r A) Top of Gmemd Sm m Efevadon odma Gis ia6o 1 s Hr G.W.Ekwatkm +the MAX ifiO G-W_ a _ C DIFFERENCE BETWEEN A and S — SIGNED: Q V DATE: f S1MCh pmposcd lbn of Sys=on badcl_ Jk 61 r r gaol THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA