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0006 SCOTTSDALE ROAD - Health
6 SCOTTSDALE ROAD, CENTERVILLE A= 229 - 120 Illl,G(llY,o � UPC 12543 a No...�3� LOR HASTINGS, MN 4U 0 i q a A d vt ))) t V r O Td 0 Li a�i.Yf H S f2'•^^" Ilk,�y �a '� �; �, r�+_ .. ..; Lam( • �� � = f , , 14•d' ua3`''el s i O E-- cn r - � - I P.y4-.VG ' _•�Vs.WW�-t.�ww:te6lpE :_ , T.laea�•wa.r�a..c v _:;ar:s�saF_sH6cr►�nJs b •_ Tr`" i+ai it Z 1 7 vwt— o lY s1 ��'4' S'�" i'•4' As �s8.ax,• �(1 4's' real+�1�-eFv} g qro• 1,•`n i.e" .�I/._�1//.1�J,�•��bN.... .� 11 � 2 d (�(/�� -�t�a 1'•a" O 91 N f . • ... . iJ oT�s.:.. 813n a�.3 BI•P.T k yl y.t 'fb'a6row nu. I 2 atryY 31T�iCA�VITPNP•.� MWMAIN�B•M��W_�f:XtlJ8y:flclsW Ncw:Picl•t'a•1°?•r'K h'T.166 ...: .. 71P...Id1fL�W�K� C• 4'•Z•p �.ld ' 1 . I I I Ior o 1 fla i s ITIW+'ro�oucEv__� a= $e �g :^ Onlvaa�++60 m. t k ;t±;y( �• k3syaa ._.•6'd"O.�•8liR.lR'..WoM r.o:c. d' �, .. �� ,.,. ��a 3!r i b _(¢p0itt6163 2MC• t _ �_�_- ^'cesr`I +vNea'ww"w- °a �I�r Q i i.l Jope* ce1.aG • �`�vt � t t} '<lyla t;.,i�' R-.'CJ]Cn al � � it t z a 5 • 1 e �. rx 1 ram.. � ass :� ' I.pd 0nr{o�mc ( t. y I II. Cn rim. y_ Tll►1.. - .� 'IN+uuHF+ _. ' :y1sA1AA•.. .f.':, /— �j Y� �,� 0 I f I o i i t':- .ulw•aoam+�• oauw-I�.cw. I - ( 'i �` * �._ -- ( _ �1.$ 8+�sd!d�ca�c.•. } Z V' --- --- --- �''`" ��Nam. t�t)INC,;1% t. ��: r�•t-:.t. � � � 1 ow.IICB HCPAPPUED y C -- P jkrtesptla�Y-vaMPRmA� .L n AS ?o t4f�.oP'PIh+:..GRAOB PRV.�W L • . r W F ql`. I,s�° 1•oa' �nt1.' ✓'-i�!,s1�4 •I�VVa • i:Y�°a•11•o , 1•� GLQ• � IIJI t o � to � tl Jan 1416,04;5* William Rose 239.689-6575 p,2 4L January 14, 2016 �a To Whom It May Concern: m We purchased the property at 1059 West Main Street, Centerville, MA 02632 oma from Margaret M. Connelly on June 30, 1998. The property,when purchased had a finished walls-out basement with three rooms and a full bath. In addition,there was a finished detached garage-studio with half bath and a floor plan as it exists today. In 1999, we pulled permits and renovated, converting the existing kitchen and living room to a great room consisting of kitchen, living and dining areas. We also added an attached single car garage.. We then petitioned and received permission to relocate the driveway from 1059 West Main Street, changing the address to 6 Scottsdale Road. We have used the detached garage for a recreation room since purchase. /ja r i William W. Rose 22- Judith D. Rose Q a � � o coT•.ES•��• � ' " -L.ca�mmrwz:•tb•vers+mv nw H . _p,Mpl/J1A1N 4B..H11:1".YN6L:tl46W H GPo11R6De�I`1C• S '.vt ••b -l�wrluai7o'THK.: C� } 6 6 eG,J<Cwl'./.p.Cf. a Bill: }d ra _... •7•r!!!ti�e ea Iry_• 4 s ` .. '- 'MIZ'wZu►."6 s. I .... 10 ='ar�au�ca'°rYc I oc r Sbf4Uaieru --AIOw-"I+SAW - =��gs� suo�—— A .>�oar.-rcta•.wo's►. W 331 Idae.rcpo,,.auua: I 'i +.env,smv ' sl I �7 ►/ zv ' moo: rihlc:-'. U H m ow{B (� C>~CO cn I ae �w � �{� �v O d] � - -- E M 14 I s ,-,. I• =e'Kr+poW�em.+e. I I `+'. �'x7k�uu1:� i ( '��� .76��41s��Qi1:. I IV tp•1C 1 •� =. N41Q1"'. I I. _._� �ti y11U. •. �ta,:le!_-� ` �i'� Lsm°arwlc.ouut es� _ - --- ^II � ' I. � ; suns•. �':. _•p4'F 91t10 f i I I vl •r�oP+>PPu 0 � 1 Ike ae Ev . n tbtasrtla.cr.d•�vl!eola�a -y —_ A5 SR oF'PH�:.'wRPr+B_ ••� Q � �j If 2 RD C r�rr,� v►��r. M �- rl 0 1� 4 r� I f r v �' 3 0 ' Tor D6 sa ` +Sxn -wces. O W e IRMI 0 '!'•off crx�Y� __� / '- !- — 5�d'FimPeaoCi[A'EC _ [. 'I 3 rx:i cux[a ol 'M_. ..-. P U �aa�eer,7 :: ...- o N � �--• .- _,to:Heestma.Ren• -=�,.a"1 � 2 IL/ TCL'41Ty' r F O .�OMsN4 I j t O lY Ed►. em. F s IE �'•S' _r•Rd3xev vwl q�•o� z,.G� �.,� _:Pa�b.t"f_I�b1�1:J.�.. ` a �n , y c� x�^ C�F�rMQn��ea�� of KH ����6U��*�// .— .-~° . ��"��Q�� �� ����°�~"��K U������������"���� �����M1�| 8 ���~~ �� �.�U0 �.=���K Inspection Q- �*xo " x n 76,r Subsurface Sewage Disposal System Fonr. ' un! usmenta qn Property Address /7 YS�_ uwms Owner's Nbrne information is | required for every ���_ | page. o�/mw.n Zip Code uwoofm�*twn - Inspection results M U St be submitted on thi s form. I rispection form s may not be altered In any way. P1oema see completeness checklist atthe end of the form. xnpnrtamt:When A. ����K������ A�6mrMN��'��� / . ~ `- Information . � on the computer, -/ �� // /luse only the tab key to move your ' Inspector.' ' ��m-nvn� .uuemommrn Name of Inspector _'. Company Name go Company Address CAy/Tow n State Zip Code ) C ' Telephone NJ�r License Number B. Certification =�. ~,`~^ �,,o���~=�n icertih/ that | have personally inspected the sewage disposal aysb:met this address and that the information reported below istrue, accurate and complete onofthoUmeof the inspection. The inspection was performed based on my training and experience in the proper function and maintenance ofonsite sewage disposal systems, |mmm DEP approved system inspector pursuant to Section 18.340 of Title 810 CM R 16.000). The system-, ras5es [3 '^ Conditionally Passes LJ Fails [� Needs Further Evaluation by the Local Approving Authority Inspecto. The system inspector ahsU submit a copy of this inspection report to the Approving Authority (Board of Health orOEP) within 3O days Ofconlplet inspection. |f the system iom shared system gr has a design flow of ',0,000 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 nonttu the buyer, if applicable, and the approving authority. | ----------- � - / ***°Thin report only describes conditions at the time of inspection and under the conditions nfuse at that time. This inspection does not address how the system will perform in the future under the aorne or different conditions ufuse. k k��njo | IM.�Yi, :°"=p=*,,�m subs�^=,�aq"oispceAe,stAm-Page^a^r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address __ Ovv rig Cw ner's Name inforrmtion is required for every 6ePi v if ! l e / 14_ / of page. Oty/Town State Zip Code Date of fnis t_ion B. Certification (coat) Inspection Summary: Check A,B,C,D or E 1 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please exPin. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits subs)antial 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. I� Y ❑ N ❑ ND (Explain below): tare; ✓13 7;tio50tfie;a1 inspm6mForm,SubsLrfaoo SowagoDlsposd G Atom-Page 2of 17 Commonwealth of Massachusetts - - Tide 5 Official Inspection Form Subsurface Sewage Disposal System Forrn .. Not for Voluntary Assessments 6 Sc o7ys c/a le Property Address Cw ner ON ner's Name information is required for every e h page. City/Town �— _ State zip Code Date of I spection B. Certification (coot) ❑ Pump Chamber, pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ 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 h•';ealth), ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (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 wiling 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 mannerwhich 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 \egetated wetland or a salt marsh t5m Y13 Title50TIC48IrSpecuaiFOmSubsuYaceSevereolsposalSystem•Page Sot17 i Commonwealth of Massachusetts - Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner Cw ner's Marne information is C�H J �� e �1 Od 6 7a required for every ��7_._.,�G_✓^_ ` � O page. City/Town State Zip Code Date of Inspection B. Certification'_(conq 2. System will fall 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 systern 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y p Y P ry coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, 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 ❑ 1 liquid depth in cesspool is less than T below Invert or available volume is less than A day flow Ong-Yi3 TOO 5OffaoftrspooOonrorrrtSuosulmeSowageDisposalSystem-Pago4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form G Subsurface Sewage Disposal System Form • Not for Voluntary Assessments l0 Property Address ON Ila ON ner's Name oS e information is Ceo .�2✓vf, Ile �l 0d_6 7� � y required for evt�y _._. pago. City/Town �^ State Zip Code Date f Inspection B. Certification (cons.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: ❑ EB 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 tribt.ttary to a surface water supply. ❑ [5' 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.] ❑ l The system is a cesspool serving a facility with a design flow of 2000gpd- ,/ 10,000gpd. ❑ 1���"�'" The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails, The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 pd to 15,000 gpd. 9 g 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 11 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. IS nS 3113 T i a e-Ogcial lrspecum Form Subsuface Sewage Disposal Systam•Paga 5o117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vy uo- (0 s�O! /s C A 4- Property Address Oov ner Owner's Name information is required for every e ..._._.._.✓_..:./ ( A/,4 --s page. City lTown „MW4 State Zip Code Date of fis tan C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Ye s C ,,-Pumping information was provided by the owner, occupant, or Board of Health El Were any of the system components pumped out in the previous two weeks? ❑ L'^ Leas 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 WA) Was the facility or dwelling inspected for signs of sewage back up? C `Tl Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? L� ❑ 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: i [1 Existing information. For example, a plan at the Board of Health. n 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 0 1-1., ,,4 0 C-of�4� Residential Flow Conditions: L Number of bedrooms (design): ---- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): �1C� 1}ss,0ssr S�Q�(�� ,¢f- ,�he� ti#g �.� 3l13 C o I I G 5 e oe 5 0 fiGa L�spWoon F crm Sut*Lrlam SewagO UisDOW SyMm•PNO 6Ot 17 �99-5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r Property Address Cw ner Ow ner's tbme information is (fP 0�✓V, required f or every --•-. State Zip Code Date of Inspection page. City Tl'Own T _....... D. System Information Description: --._ .�•-_...._....._� X 6 �ie—bus � �� c✓f �� o� �`� S4-o vle— Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection [] Yes 11 rvo information in this report.) Laundry system inspected? ❑ Yes o Seasonal use? Yes ❑ No Water meter, readings. if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy Date Commercial/industrial Flow Conditions: Type of Establishment. Design flow (based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow (seats/personslsq.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'. ?ioe 50friciA IrspectlmFtrrt"utKilace sewaaenispoO System'Pap 70f 17 t:Sre�•Y13 i Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form/ Not for Voluntary Assessments �2 Property Address oN tier Cw ner's Narne �/�' inform ion is G e �� / Q !•L required for every --- -- --"— state Zip Code Date o nspe tion page. City/l"own D. System Information (cont.) Last date of occupancy/use. Date Other(describe below)_ General Information Pumping Records: Source of information: part of the inspection? ❑ Yes . No Was system pumped as pa p If yes, volume pumped. gallons Howwas quantity pumped determined? Reason for pumping. Ty;�SySeptic tank, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Pnry ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Altemative 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 C7 Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): u�s OFfiva i Gpoctm F crm Subs 0XQ Sewage DiSP0Sa SMm•Page"17 Krn•3M3 Commonwealth of Massachusetts' Title 5 official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments _ y�Co45 C a le led y Property Address Cw ner Ow ner's Name // information is C2✓1 ✓v''/` le /•'1� 0O 6 4z -g � 1-5 required for every _ / ' -- page City/Town State Zip Code Date o Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes E5' No Building Sewer (locate on site plan): 33 Depth below grade: feet Material of construction, ❑ cast iron L,_' 40 PVC ❑ other (explain): O Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Matena construction concrete 7" metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Cortificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No S Dimensions: /i Sludge depth. t5m N13 ?�JUSG�tlaaIMp©c DO,F,Zrn5uwwowSCWCg00'ispocdsyotom•Pogo oof17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System I Form _ Plot for Voluntary Assessments, �Y 0 ITS�c. e Prop"Address _._.. ... OS� ow ner on ner's NO y information i e Ce✓� �Ll t I T IT t�6.� F required for very __.._..._._._.._.................._.._�..__ page. City/Town State Zip Code Date Ins tion D. System Information (cont.) Septic Tank front.! Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Ole("4 G G Comments (on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 40 Grease Trap (locate on site plan)., Depth below grade: feet Material of construction: ❑ concrete L: rrietal ❑ 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 tSrr..V13 Tice 5Olfida1 IrtSpecua1Fam Surface SevageDispasal System,Ne to a 17 Commonwealth of Massachusetts v tle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s, 6 scc T7s C✓ca /G / C Property Address Ow nee C w ner's tbrne information is C�vt �/(/y •e required for 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, eudence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Matenal of construction i l concrete l;? metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: capacity. gallons Design Flow. gallons per dad .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 •yt3 7 cSOfficlaf Ire PmbcnFOrm Substrfoct SowogeDispoed Gwtom•Pogo 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form - 'plot for Voluntary Assessments Property Address rJS � W Ow ner 5 na's Narr>E "5 information isN ✓!// 6 /e required for every - -- ---- ----..__.._.__.....__.._.._-._........__�__ State Zip Code Date of Inspection page. „ityRown D. System Information (cons.) Distribution Box (if present must be opened) (locate on site plan): �ok".- Zc)C Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence, of leakage into or out of box, etc.)'. //0 /lrn o�► s— �, / Pump Chamber (locate on site plan): Pumps in working order ❑ Yes ❑ No* Alarms in wort<ing order ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.); if pumps or alamns 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: Tice 50 nab jm pecucn r am Sutwu face Sewage oispor.4 SAtem-Pao 12 of 17 6r%s•yt3 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C ofls c-J,, L 12d Property Address / Q S Pi information nmr pvner's Name /� I„ ! lZ �/¢ Q� intormatbn is (fie 'w✓ required f or every ._ _ __..__......_ . _. page. City n State Zip Code Date of Inspection D. System Information (cont.) Al Type �/ _) 7L [. leaching pits 0 number. leaching chambers number: leaching galleries number: leaching trenches number, length: [D leaching fields number, dimensions: 01 overflow cesspool number. (. innovative/aitemative system Type/name of technology: comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation. etc.). Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number ant 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 Cl No Gillis y13 Tile 5OM06 irspOCbWFcrrr[Sumu-tace Sewage Disposal Sy3tem•Page 13d V r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address� -..'^.,..,•_. .._...._._.�. ...�� Cw ner Qv ner's Nam, Information is , 7F,.—required for every ..,__ �� page. City/Town State Zip Code Date of 1h6pection D. System information (cont,) Communts (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.): �.yq3 ?itic5 (fiaa ImpmbalForm Subsutaw Sewage Dispmd Systam•Cage 14 d.17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments property Addre�,s Ow ner Cw ner's i bnv information is required for every page. City[Tow n State Zip Code Date of Inspection ®. System Information (cons) 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 p c water supply enters the building. Check one of the boxes below. hand-sketch in the area below drawing attached separately /V1 t f S 1 /ia - 3,? ern,319 ide 50tlaai lnspecomFcrrrr Submrfam Serw�pe0isposd System•Pep 15 d 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C/� Property Address� Ow ner OW ner's Nana; information is I// requiredforevery iy��� .. ✓� S page. Cky/Town State Zip Code Date of Inspection D. System Information (cont.) Site t xarry Check Slope ED Surface water Check cellar zoo ❑ Shallow wells Estimated depth to higr,, 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 property/observation hole within 150 feet of SAS) (� Checked with local Board of Healt explain: T L S �7o ❑ Checked with local excavators, installers - (attach documentation) (� Accessed USGS database - explain: You must describe now you established the high ground water elevation: 611-0 40&.117 L9 7-- /2 10 t-� V-7 Ile I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5m•W 3 1.-c 5,)Mcsa trtspecnm Form suasuface Sevmge oispmai Syswrn-Page 16 or 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage ©bsposaI System Form - Not for Voluntary Asse"rneM Property Address corner aN nos nra� requir dfo a �G required for every _�� page. Ctty/Tow n _ _ State Zip Code Date of hspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked 3-Inspection Sw-nmary D (System Failure Criteria Applicable to All Systems) completed L Sys Information - Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file LSGfi'313 r@e50mda W*pwdwFum$uWutaw S""eMWoW Symem•Page V ci 17 20 FT. M//Y. , /V OTE = /F E'/TNE.Q 7W.1 S APT/C 7-AV/< O,Q /= Ef1Ct///VG P/T ARE 7H.9,,"/ /2"BELOIt/ /O wr. MMol 1,4AOE/ f� 24 'O/AMETEK ['ONCRET� �Ot�ER 4'PYC 0/Pl sNALt BE BROUGHT TO G.qA L> CDNCRCTE NE�YY C^ST /RO/V COVER Sf�AL[_ QE USEO EL=9g.5 FOYERS �B'vF,Q Fr /F//1/ DR/VE11/AY CLEAN SANA9 -- UgZ1140 LEVEL 4"CAST 2"LAYER MIN.MIN.P/TcN PIPE IDOS G.441-. o a o o o - GiF //8 -J�B" , %4,Rex —r. SEPTIC TANK D/sT, o o ; • • � ; oD•4o W.45HF0 STONE BOX • s Ir . . � f ' • b 1 • aEFFECT/YC • * . r 314'- / �2 • D e 1 6 p�TN • r I • • o WA5.YED STaiVE t v 1 • • • • • • • c o • • • v I 1 • • • • • 1 1 IBg.S X Z.S = 4-71 G/D �• r. I • • • • • , D , PiPECAST snscA, GE INf�B'� CLEf�AT/oNs ° ►• • • • • • • • `o P/T DR EQL11V /INVERT AT dU/LDING �� 5 FT- -77.5 x 1.0 - TR G f D 6 A-77 D/AM. • a EL- T2-5 /,vz-ET SEPTIC TRNK g9.3 FT PtT•CAPAC-+?~f 5Q•9 6,1p ((O FT. 01AM. �CCSEETABULATJOA�) OUTLET SEPTIC TANK g9, I FT- ` //VL.ET D/STR/BUTION BOX S7 9 FT. SECT/QN aF. GROUNo PV,47TER TABLE OUTLFTD/STRIBUT/ON BOX ':�g•-7 FT /NLFT LEiaCNlNG PIT 22, 5 FT SEJVAGE OISOOSAL S)e.ST,�M TABULATION L EACH/,�V 6 p/T DES/GN CRITERIA .SCALE %4'' _ /=o- D/MENS/O/V A 9.0 FT. D/HENS/aN $ �•O FT. NUMBER OF BEDROOMS 3 D/HENS/ON C 4•o FT. (Mla l GAReAGED/SPOSAt (IiYIT �o�c SO/L LOG / TOTAL EST//*IATEp FLOK/ 33o GA1.1DAY SO/L TEST */ SO/L 7ES7-#2 SD/L TEST NUMBER QF 4"ACHIn/G PITS f^ELEy q0.3 ELAFj! pATF OF SOIL TEST �lov. 1� 1 9� I S/OF L-CACHING PER ro/.T � gg Sf•t FT. LOAMRESULTS iV/TNESSED BY 2 FA(P--gAQe- C—IFF�ok6 SO7TOM LE,+ICN/NG PER P/T � PCRCOLAT/OlY itgT� LASS TOTr1L LEACH/iYG SQ. FT. SvL / M/Ivy//NCN RFSBKVEGE,4CN/NGARLEA n�oCu SQ. FT. ��: c '�COLA7'/ONRA7-E/ 2 /L ,y/N./INCH 1 OF CLEAN M, c LSR OF 4 44, Z -I2 Ad D LET LI- VI/EST MAI►J S-r>��T JONSf`Nd o�' 9�y t �` %\ PHILIP, Vr+1C. 624\jE i_ v 274 v yYEiNBERCa yI :;, I Fes/ ��0� 9�F Na 356�Q ', EL DREDGE ENGINEPRING CO,/NG. Np �F�O ocFcG`�37E� \���" EL�8.3 712 MAIN ST. • f/YA,t/N/S, tiJgSS f SUR S/ONALEN6 ❑ NDGROU/Vo Yt44TCR ENCOUNTERED GL/ENT: AugLU` /jgTE JAW 22,82 GIZO UVO yVA TE.Q ,9 T EL Ei! _ .JOB NO.• --_9 SHEET OF 2 Town of Barnstable Page 1 of 1 3� Go Back Building Details Land Building $162,600 Bedrooms 3 USE 1090 value Bedrooms CODE Replacement Lot Size $97,906 Bathrooms 1 Full 0.46 Cost (Acres) gi s Model Residential Total 5 Rooms Appraised $ J nt� " `3�'�,0 Rooms Value 168,900 � � S Style Ranch Heat Fuel Gas Assessed $ T Value 168,900 Grade Average Heat Type Hot Air E I Year Built 1982 AC Type None Effective Interior, I" depreciation 13 Floors Hardwood Interior Stories 1 Story Walls Drywall Living Area 1,053 Exterior Wood sq/ft Walls Shingle Gross Area 3,350 Roof Gable/Hip sq/ft Structure Roof Asph/F Cover GIs/Cmp Building 4%e11a ,, Land Building $162.600 Bedrooms 1 USE 1090 value Bedroom CODE Replacement $77 977 Bathrooms 1 Full Lot Size 0.46 Cost (Acres) Model Residential Total 2 Rooms Appraised $ pp Rooms Value 168,900 x Style Cottage Heat Fuel Electric Assessed $ _ Value 168,900 m` Grade Average Heat Type Eleo Baseboard i ear Built 1995 AC Type None Effective 8 Interior Carpet depreciation Floors p GF i Stories 1 Story Walls Interior Drywall4 :.. Living Area Exterior Wood sglft 620 Walls Shingle Gross Area 620 Roof Gable/Hip sglft Structure Roof Asph/F Cover GIs/Cmp http://www.townofbarnstable.us/Assessing/printsketch.asp?mappar=229120 8/8/2015 No. .R..6 THE COMMONW6LTH OF MASSACHUSETTS BOARD OF HEALTH 774 V� .......................0 F........... A. .................................... Appliration for Disposal Works Tonstrurtion Wratit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal system at: I r ........ 16) ........... ....... (knoll.. fl.&................................. L a -A.M-F� T.*r""'Lot N7 .....BL_ /V C' ........................... . ...... j.....................eA.............. Owner Addre.. .......... J'M ddress Type of Building Size Lot._.;2.Qj_Q.Y2Sq. fee� Dwelling—No. of Bedrooms.............I.............................Expansion A Garbage Grinder 014 P4 Other—Type of Building 149J�:��..CgAqgNo. of persons..............�ilc........ Showers Cafeteria 04 Other fixtures .......................................................................................................... < ' Design Flow..............!��.......................g-allons per person day. Total daily flow..............i. .... Liquid capacity............gallons I Diameter................ epth....r Septic Tank 6.... Width...Y, D Disposal Trench—No..................... Width....................Total Length.....................Total leaching area....................sq. ft. Seepage Pit No........./............ Diameter.....J.P......... Depth below inlet.......(0.......... Total leaching areay.�4.6....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. I................minutesperinch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............... FF. ::: . — I- 0 . .....777-------------- .9 4-N14 S - .' 3" g.......................ST-5;-- ------------ --- D loil of Soil........ ... .......................... :::::-:( t, ................ . .... .................................... ---------- .........)........... . ..... ..nn ------------------------------------------------------------------------- ....................................................... ............................................................................I....... mk� 'i.....**------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescrib d Individual Sewage 9isposal System in accordance with ed,fu the provisions of'JI'L LZ 5 of the State Sanitary Code The undersign ::Dnfr agrees not to place the s tem in operation until a Certificate of Co HE 4s been is, u y thte, a sf SigneSip �'f' d ... ......... . ..i....... cm�....................... D Application Approved By........ ...... .. . . ... .. ............... ........ ...... ... ................. Date Application Disapproved for thLe reasons:.............................................................................................................. ....................................................................................................................................................................................................... Date Permit0...................................................... Issued....................................................... i.. A* . ¢ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �...)........................OF...........?, ' 6 ' rlutttiun for Disposal Works Tonstrixrtwn rrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ..Q .... ............... bt System at: .W a ^.•.`..Ia _...... .V Own er • .l..;.. ..•......._._.-•• s N� ocation-Addr _ d v'....._... . .r2 . V.A_J � .... ........ ..... Address .... ............................................4d.bw..r Yl Installer Address Type of Building Size Lot._,?.n ..Q_ O.Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder W/A a Other—Type of Building 1J- J-�-+7---F!A0!ENo. of persons..............t-� .._•--•---- ShowersCafeteria ( ) d Other fixtures ......... ............... -- ....... ...... W Design Flow..............<5........................gallons per person ear day. Total daily flow._........__,. ��......___:._.___..gallons. WSeptic Tank—Liquid capacity............gallons Length._' --6.... Width.-25e�Aq-.. Diameter:.„............. Depth... .. _.. x Disposal Trench—No..................... Width.................... Total Length.............. Total leaching area.............::.....sq. ft. Seepage Pit No........�._......... Diameter...../a.......... Depth _below inlet.......& ......... Total leaching area�26.�.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.........................=.............. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o / .. Descri tion of Soil........9k 3 ", = �.. l v�Q�??�{,p � ... p .use....... .. ...................................................... . x ••-•••••••-•------------•--••-•-•--•---•••-----••••----•-•---•------••-•-•--•---•-••••. ...1..••••- ......... V Nature of Repairs or Alterations—Answer when applicable.......................................................................:. ................... ------------------••--------•--------•--.....................-----......-•--..............---_..... ...............•••--••--•--•......... ....•••----•-..............-•• �----••------....----- Agreement: The undersigned agrees to install the aforedescrib d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is. u- `by'the boa d of healthl. Signed._':............. '. ._.;.._ __.___ _..'..,...___..7` �..\ �e ...... .... Application Approved By.._....._•-•-•...---_. .c.1�f e T ........ 1. ........ =Application Disapproved for the f oll9wing reasons:.. ........................ ....................................................Da t e-_•,••_,-•. --••----•---....---•...........................................................:....................._.---=--.........--------.....-•---------...------------...--------------------•----••---••--•--- Date PermitNo..................................................... Issued..-----••-•-•-• -•--••--•-•----••._.......--...... Date THE COMMONWEAf TH' OF MASSACHUSETTS BOARD OF HEALTH ........... . ........OF....._4 �4.......................................... (9rrtif iratr of Tuutplianrr THIS IS ,CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( ) by................. ...._.......ro t......---•-••-•-•----••--• ---- --------------•-------. .................................................................... � Installer / J at.•--•-........ f m has been installed in accordance with the provisions of T!T. E, j, �l The State Sanitary Code as described in the application for Disposal Works Construction Permit No.,0.2•,-.6-__.....L.._._..... dated__...__-__._i................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA TO DATE..... .............. Inspector. ..._. THE COMMONWEALTH OF MASSACHUSETTS �-y� BOARD OF HEALTH No fit,, .. ,,r• .....OF.. .................................. i`y''� . FEE---?s........... Disposal.Works Tuatuttr_it�tuan rrmit Permission ' hereby granted_-._,,.,,.��_ - 0.':(.�.--•-----L.-D �'---:....-"--••-•-----•-•----------•------•.................................•--- to Construct ) or Repair ( ) an Individual'Sewage Disposal System atNo.... � •--.:_..` ., ------------------------------------------>,...� Street as shown on the 77 ion for Disposal Works Construction Permit No..................... Date ------------------------------------------ DATE_.3 % Boa o eal FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS N e. 20 FT. MlAif.- /1lOTE /F E/TiYER THE S�PT/C 7,4/v OR ,7_EACII//VG O/T ARE MORE 7-141 .A/ /2"BEL0 $,V /O f7 .M/N.. r.eAOE� fa 24'O/.4M ET.ER COiYC.E'ETE COio�ER f GONCRCTE 4'PYC p/PC S�ALC B'E BROU(S V7 TO �.-+,'✓ EXTR.q -EL= = M/N. P/TCN i"�E'4Vy C�'1 ST /RO/Y COI/FR S//.4 L L L3E USE.0 ,.. CODERSFT. /F/N DR/VEIt/.4 y Aa MiN. CC/VCRE•TE _ G AOE CO rER CL EAN .SA/V O EL=9o.0 i _ BAC'fe 4L . LAYER All Al.AMCW G/1L I4 OEit WA S 14r T. o• e I • • • • • • r r e �4 MFO 57ONE .SEPT/C. TA/VEC D/S eax o s r • . . r.• e . , / ' N r t-•EFFECT/VC r ` • , 3 4 e r r • DEPTH • • • • • v v WA5RAFl> STONE t r • • • • •.► r ' boo , 1 ,5 x 2:5 = 4-7I !��(� r`� • • • • • r p PRECASTSEE.PAGE JAIV Tf CLEY.4T/DNS a a�.' r • . . • . . r ••�o P/7 OR EQU/V .NYERT AT DU/LD/NG . S FT. 6 FT OIAM. /NLET SEPTIC rA VK •3 I FT O/A1H. C(5CeTABUL.4T 6A/ 3 FT, PI T•C�PAC IT� ��. (mil D (� QITLE FP T %NLET O/STiq/81lTlON BOX g2 9 FT. GROUND /tr�ITER T,48LE ' OUTLETD/STR/B/lT/ON BQX �g.-7 FT SECT/ON OF _ /NLET LEACHING; oi7- gQ. 5 FT. SEWAGE DATRO SA 1. SY.STEJtif t LEACH/,+i/G P!T -rA BUC AVCN / DES/GN CR/TER/.�t n z •_v DIME/V.S/O N A 9.0 XT y StALE �s^ NtlMBEi4 OF 9EDROOMS. 3 D/MENS/ON C 4.o FT. (MtcJ} cAR4%AJGAr,&154p0s"t uivir r roc SOIL LOG SD/L TEST. f TQTAI- EST//►?ATEG FLO*V 330 GAL.IDAY . cS01 L TEST,*/ , $O/L 7EST*2 NUMBER OF LEACHING PITS I f` r^-ELFY, -I�OV I� 19g 1 S/OB Lr'ACH/NG PER PIT 18Q ELG•K 90.3` f pATE OF -SO TEST Sf FT. LOAM RESULTS WITNESSED BY i2•PAI2F3AWK GirFb2b c90TTOM 4Z4CII/NG PER P/T $Q, .rT p`-2� B( PCgCOL�4T/OJv RAT�,�E/ LESS /yI /NGM TOT.1L LE,4CH/NG �4REA 2(0� SQ, FT. S�f3s��L I��tCOL.4T/GN RATE f2 TFtAa:( M/N.11NGN RESEI¢YE LEACNI)YOF AREA 260C. SQ. FT. ` 1 2,p t-a OF Af, t MED H of,yqs�. . 2.:-12 SA►J D LoT L�. W��S/T� NM AI Q S �'�" �H v, o`' °y sr C�1.1 I e�V(l..l._ a PHILIP, E�pd�'L u WEINBERG 4 2487400 0'$ No,366 0 L DREDGE ENGINEER/NG CO,/NG. i, O/31 f O� 9p �Q/3T F EL fig.3 76 2 MA T//Y S . , �.Al YQAI ViS. MASS Hp SUR`1 '�S/pNAL'ENG�� - 0 •ND 0,TOUNO 1-V,4TL-R ENC0U1V7'4rREO K- CL/ENT:�u t3t.UL P q7 E: J A N 2Z , (� G/'Ro uvo WATER AT EL EL! \F Joa NO., �LoO _ SHEET 2 OF 'L t Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection rad One winter Street' Septic Boston,Ma. 02108 .John Septi D.E.P.11.E.P. Title V c Inspector P.O. Box 2119 Teaticket, MA 02536 wlLUAnn F.wELD (50 )564-68,13 GovernorN� ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �, R fCE'VEL PART A CERTIFICATION FES � 2 199 � 8 Property Address: 1059 W.Main St.Centerville 1 Address of Owner: E4�BARNSiAg� Date of Inspection: 2/2198 (If different) OEpT Name of Inspector: John Graci Donnelly:3 Valley St.Malden Ma.02148 P / I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: ti 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 This Inspection Is based on criteria defined In Title V Conditional) P code 310 CMR 16.303.My findings are of how the system Is y ses performing at the time of the inspection.My Inspection does _ Needs F the valuation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature: Date: 2113198 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 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 authority. INSPECTION SUMMARY: Check A, B,C,or D: AJ SYSTItiM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B1 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is 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 0441707) One Winter Street • Boston,Massachusetts 02108 is FAX(617)556-1049 is Telephone(617)2925500 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1059 W.Main St.Centerville Owner: Donnelly:3 Valley St.Malden Ma.02148 Date of inspection:2/2198 _ Sew.acte backup or.breakout.or. high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: 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 C3 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. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other i D3 SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: 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. Yes No 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. (revised 0427A7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1059 VU.Main St.Centerville Owner: Donnelly:3 Valley St.Malden Ma.02148 Date of Inspection:212199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 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. 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. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CH ECLIST Property Address: 1059 W.Main St Centerville Owner: Donnelly:3 Valley St.Malden Ma.02148 Date of Inspection:212199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — 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 period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. x As 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 non-sanitary or industrial waste flow. _c_ — 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 — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 0Ar17l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1059 W.Main St.Centerville Owner: Donnelly:3 Valley 8L Malden Ma.02148 Date of Inspection:212199 FLOW CONDITIONS RESIDENTIAL: Design flow: 33D g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: U Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes Water meter readings,if available:(last two(2)year usage(gpd): rVa Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: We Design flow:0 gallons/day Grease trap present: (yes or no) 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: nfa Last date of occupancy: Ma OTHER:(Describe) rds Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No .If yes,volume pumped:a gallons Reason for pumping: nla 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) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source Information: 16 years Sewage odors detected when arriving at the site:(yes or no) No (revised eal27)871 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1059 W.Main St Centerville Owner: Donnelly:3 Valley St.Malden Ma.02148 Date of Inspection:212198 SEPTIC TANK: x (locate on site plan) Depth below grade: V Material of construction:x concreate_m eta l FRP Polyethylene_other(explain) If tank is metal,list age rue . Is age confirmed by Certificate of Compliance_No (Yes/No) Dimensions: Le'6^h5'r•w4'1V Sludge depth:t" Distance from top of sludge to bottom of outlet tee or baffle: 2e" Scum thickness:U Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:g How dimensions were determined: Measured 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.) Septle tank and all components are structurally sound and runetloning property.Recommend pumping every one to two years. GREASE TRAP: (locate on site plan) Depth below grade: He Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nta Scum thickness:nta 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: rds Date of last pumping;,t, 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.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade: ve^ Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4" Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04117)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1059 W.Main St.Centerville Owner: Donnelly:3 Valley St.Malden Ma.02148 Date of Inspection:V2198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_m eta l_FRP_Polyethylene_other(explain) Dimensions: nfa Capacity: Na gallons Design flow: ryagallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Nt DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rya PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)Eo Alarms in working order(yes or no)_Yea Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) rya (revised 04121197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1059 W.Main St.Centerville Owner: Donnelly:3 Valley St.Maiden Ma.02148 Date of Inspection:212199 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: rda Type: leaching pits,number: 1A=gallon leach pit leaching chambers, number:nla leaching galleries, number: nla leaching trenches, number,length: nfa leaching fields, number,dimensions:rJa overflow cesspool,number:nla Alternate system: nra Name of Technology:_nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The overflow le strucluraliy sound and functioning properly.It was empty at the time of the Inepeclion.It has not had more than T of water. CESSPOOLS: (locate on site plan) Number and configuration: rUa Depth-top of liquid to inlet invert: rya Depth of solids layer: nfa Depth of scum layer: rya Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: rda Dimensions: ria Depth of solids: rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n!a trevleed 0Q7l871 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1059 W.Main St.Centerville Donnelly:3 Valley St.Malden Ma.02148 212198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) l�b 4� Ian f�C Pays ! of 10 (revised 04ITST) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1059 W.Main St.Centerville Donnelly:3 Valley SL Malden Ma.02149 212198 Depth of groundwater, 10. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. X Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) Ground water determined by Hand auger (revlaed04=97) Patio ><0 of 10 _ c 1 2 le N S y r Tt3 t w de �2. `°--.w Ham. auws+u.- -.,.., � �--»-... _....,,,,,•a,4,— ,.,... - -------... �c • ToP e11 94.1 - { -q-7 t 44 940 0 'is '- 00 t ;c�c��,E cFiar, ►�*t t* _ ^�... CkIC> l�e4Cw-rtf„jL`iF`ar �- -� r ,• [[''�� . � ' � ' 7 0 r PRLFILES AND DRAINAGE DESIGN J APPROVED AS PER SUBDIVISION r r RULES AND REGULATIONS. TOWN of BARNSTABLE - ENGINEERING DEPT. oc3 CO- •� �� "�M,4,�" � ti TAalk �CXX'•.i YC"t{„f ni 1Ly y1•? ` ,i _-,._- --._,.. _.- .. A 7:,r T r,et, s � r ` iL r- '' Ext5Ti.klt� SPOT ELEVA-1 WN 0.0 £XfS1-iWb CphtT'auR p -" � F-iwi5w r, SPLIT ELEVATION p-0 1 F i N t SHE fS CON TOUR ---[- -_ AWP-OVGD : avAP•o of HEAL T H � � I� �A—�'� q C�E►.1T f a { r!t Lam.., . • i3i If p f{ r.. ._._.. i WEINSERc= _ - a t � > �"► I Mo 366 iFc a/c:,l Yt + yI" � >. r