HomeMy WebLinkAbout0132 SCUDDER BAY CIRCLE - Health 77
132 Scudder Bay Circle
Centerville
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
j= a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When q; Inspector Information �.+r 15
filling out forms 3 y
on the computer, Armando Panto a
use only the tab 1
key to move your Name of Inspector
cursor-do not Joe Martins dba Accu Sepcheck LLC
use the return Company Name
key.
Co Nortpony Address
Drive
� Company Address
South Dennis MA 02660
City/Town State Zip Code
,ena„ 508-385-5891 SI 14296
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
64,40� + 4/26/2021
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�9
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
PUMPING OF SEPTIC TANK IS RECOMMENDED.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic k (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration o nk failure is imminent. System will pass
inspection if the exisX1aed with a co ying septic tank as approved by the Board of
Health. PA metal septic tanio If it is structurally sound, not leaking and if a Certificate of
Compliance indicatiless than 20 years old is available.
❑ Y ❑ Nxplain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
r
c Commonwealth of Massachusetts
f Title 5 Official Inspection Form
(n
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ ND (Explain below):
❑ distribution box is leveled or replaced El El El ND (Explain below):
AfZ
❑ The system required mping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass i ection if(with approval of the Board of Health):
❑ brok pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ struction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Healt
❑ Conditions exist which require further evaluat by the Board of Health in order to determine if
the system is failing to protect public hea , safety or the environment.
a. System will pass unless Boar of Health determines in accordance with 310 CMR
15.303(1)(b)that the system i of functioning in a manner which will protect public health,
safety and the environme
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: .
❑ The system has a septic tank and soil absorption system (SAS) a he SAS is within
100 feet of a surface water supply or tributary to a surface waters ply.
❑ The system has a septic tank and SAS and the SAS is wi n a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the S is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
Ai
** This system passes if the well w r analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absen nd the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provide hat no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
V
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to dogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000 d-
9 9P
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No /�mnapped
❑ ❑ the systemt of a surface drinking water supply
❑ ❑ the systemet of a tributary to a surface drinking water supply
❑ ❑ the systemitrogen sensitive area (Interim Wellhead Protection
Area— IW Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
�
The. P
® ❑ Were all system components, e%aknttng the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>r
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
Description:
1500 G SEPTIC TANK, DBOX AND 5 (3050) INFILTRATORS IN A TRENCH CONFIGURATION
WITH 2.25'STONE AT ENDS AND TAT SIDES.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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)): 108 GPD
Detail:
2020: 36,000 G ; 2019: 43,000 G
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/26/2021
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gall s per day Y(9Pd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes/ed
dischas to:
Industrial wast present? ❑ Yes ❑ No
Non-sanitary wed to a Title 5 system? ❑ Yes ❑ No
Water meter re ' le:Last date of ocDate
Other(describ
3. Pumping Records:
Source of information: JUNE 19, 2015 CAPE WIDE ENTERPRISES LLC
PER BARNSTABLE TREATMENT PLANT.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
AGE: 14 YEARS ; INSTALLED: 2007 ; SOURCE: PER BARNSTABLE HD
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
NO EVIDENCE OF LEAKAGE.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
> Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'X6'X5', 1500 G
Sludge depth: Sir
'f rr
Distance from top of sludge to bottom of outlet tee or baffle 25
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
CORETAKER
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 RECOMMENDED AS SOLIDS ARE MORE THAN 20% OF TANK VOLUME.
PUMPING RECOMMENDED AT 20%. HAS PVC INLET TEE AND PVC OUTLET TEE WITH 14"
LEG AND GAS BAFFLE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO EVIDENCE OF
LEAKAGE.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of o et tee or baffle
Distance from bottom of scum to ottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumpin to top
inlet and outlet tee or baffle condition, structural integrity,
liquid levels as relate o outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pu ed at time of inspection) (locate on site plan):
Depth below grade: n� NOT APPLICABLE
Material of construction: �1
❑ concrete ❑ tal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
c Commonwealth of Massachusetts
�
Title 5 Official Inspection Form
1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ s ❑ No
Alarm level: ;- switches,
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: DateComments (condition of alarm a etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
. Depth of liquid level above outlet invert
ATINVERT
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.):
DBOX IS IN GOOD CONDITION WITH 1 PIPE IN AND 1 PIPE OUT. NO EVIDENCE OF SOLIDS
CARRYOVER.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
cry Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition pumps and appurtenances, etc.):
* If pumps or alarms are n in working order, system is a conditional pass.
11. Soil Absorption Sys m (SAS) (locate on site plan, excavation not required):
If SAS not locate , explain why:
I
Type:
❑ leaching pits number:
® leaching chambers number: 5 (3050)INFILTRATORS
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
i
c Commonwealth of Massachusetts
M Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS TYPE: 5 (3050 INFILTRATORS WITH 2.5'OF STONE AT EACH END OF LEACHING AND TAT
SIDES.)
LIQUID LEVEL: 2"
STAINLINE: 0"
CONDITION OF STONE: CLEAN/DRY
GRADE TO SAS BOTTOM: 5'
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth"of scum layer Gt
i Dimes C sons of cesspool
Materials of construction
Indication of groundwater inflo ❑ Yes ❑ No
Comments (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
AA, Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
tJ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: NOT APPLICABLE
Dimensions NOT APPLIC LE
Depth of solids
NO PPLICABLE
Comments (note condition of soil, signs o ydraulic failure, level of ponding, condition of vegetation,
etc.):
NOT APPLICABLE
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
n
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official InspeclJon Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
r= F Title 5 Official Inspection Form
4�e
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 18
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
GOOGLE MAPS, CCC GROUNDWATER CONTOUR MAPS OR JOHNSON &DAVIS
MAP, FRIMPTER.
You must describe how you established the high ground water elevation:
SITE ASL IS 27'. GROUNDWATER CONTOUR OF—4'ASL. MAX GROUNDWATER RISE:5 5'.
GRADE TO SAS BOTTOM IS 5'. SEPARATION MATH: 27-(4+5+5)= 13'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
f
c Commonwealth of Massachusetts
M Title 5 Official Inspection Form
r- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle Centerville MA
Property Address
Jeffrey C Swartz 132 Scudder Bay Circle
Owner Owner's Name
information is required for every Centerville MA 02632 4/26/2021
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
J
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c,M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
Use only the tab 1. Inspector: co
key to move your
cursor-do not Ricky L. Wright
use the return Name of Inspector j
key.
B & B Excavation, Inc. ' t
reb Company Name
14 Teaberry Lane M
Company Address
Forestdale MA ' 02644
Cityrrown State Zip Code- �y
508-477-0653 S14595
Telephone Number License Number
1
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11/22/10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner..
and copies sent to the buyer, if applicable, and the approving authority.
****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.
Iv
t5ins•09/08 Title 5 Official Inspection Form:Subsurface SewagY Disposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or."No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
J
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M0 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): n/a
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2008
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
11/21/07
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appears to be in good condition. No sign of leakage
Septic Tank(locate on site plan):
Depth below grade: 15"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions:
Sludge depth: no sludge
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. Tees present- no sign of leakage
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No-
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
v u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown 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.):
At time of inspection d-box appears to be in good condition. No sign of solids carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: (1)40'X10'3"X 2'
❑ 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.):
At time of inspection leaching appears to be in good condition. No sign of hydraulic failure or damp
soils- leaching consists of(5) infiltrators surrounded by washed stone
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments note condition of soil signs of hydraulic failure level of ondin condition f
( 9 Y p g, o vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner information is Owners Name '
required for every Centerville MA 02632 11/22/10
page. Cltyrrown 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
�i �o►.� 6
LA __F
O
A 15G'2 '
Z31 = 25'6 „
AZ: 53 '
B2. 37-611
A4
_8 4 . 32..6
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >20'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
132 Scudder Bay Circle
Property Address
Robert Dowling III
Owner Owner's Name
information is required for every Centerville MA 02632 11/22/10
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
&1rVJ51qVe-T73W2Ve
/>�ST LE
LOCATION SEWAGE#2M7
VILLAGE L,eyllftill, ASSESSOR'S MAP&PARCEL
1. [! N
INSTALLERS NAME&.PHONE-NO. � ��o�,.
SEPTIC TANK CAPACITY /SO /
LEACHING FACILITY:(type) ,� T1t� Orf (size) -30- T411
NO.OF BEDROQA4S
OWNER Hoied 1 dW ;t)
ra -
PERMIT DATE: 1U /6 ® COMPLIANCE DATE:
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 leaching facility) Feet
FURNISHED BY
A Houx -
2 = S 3
A._�3°
^.3 38
! w SS/`
i
TOWN OF BAR 4STABLE
LOCATION 1?� �Cv�� /3 "� . SEWAGE# ` 7 VW
*�ILLAGE ASSESSOR'S MAP&PARCEL 11 e71--fe
INSTALLERS NAME&PHONE NO. 7'M-7(i
SEPTIC TANK CAPACITY /,�?XJ GGG
LEACHING FACILITY:(type),?:Z 4 4, 3p� nr (size) Va K dam,, -iX,2
NO.OF BEDROOMS
OWNERav/
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility rf Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY _ Zg ,��Ot L�y�
R�?r Ili r
C4
a
03-
i
ON.. . 8 ' i Fee V�O
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplication for �Biqo r p6tem Co=stern
n Permit
Application for a Permit to Construct( ) Repair( Upgrad bandon( ) ❑Individual Components
Location Address or Lot No.�3 �'cI./�— l cc� Owner's Name,Address,and Tel.No. f h9
/73
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. � 'u�o J` o`'�`�< Designer's Name,Address and Tel.No./a'v
Type of Building:
Dwelling No.of Bedrooms Lot Size �,��'!(o sq.ft. Garbage Grinder (
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) we gpd Design flow provided 7�/f-3 gP d
Plan Date 7L/ TaZ YV '7 Number of sheets / Revision Date
Title 517ee 14? � i3�2- '/' / a7 A ' C/�e 4�1/�r
Size of Septic T� 00 64 W eJ e Type of S.A.S. f
Description of Soil 51 i
Nature of Repairs or Alterations(Answer when applicable) fit/ 444e.-I
f op
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B of al .
Si Date � ��
Application Approved byOZU&-,�MlfDate
Application Disapproved by: i Date
for the following reasons
Permit No. Date Issued
v Fee
r
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC'HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for aiopo aY *P!6tPm Cowa ction Permit
Application for a Permit to Construct( Repair( Upgrad Abandon( ) ✓.Complete System ❑Individual Components
Location Address or Lot No. _ Owner's Name,Address;and Tel.
Assessor's Map/Parcel /7 �, 77 r Q B' 7 0 // �
Installer's Name,Address,and Tel.No. o Designer's Name,Address and Tel.No.
S7j a•z c• c?(� dYl. l''1 /� tMr7 4/S7// Y..b.,hj-,l W/Y-
Type of Building:
Dwelling No.of Bedrooms Lot Size' z t,`�r°J(/ sq.ft. Garbage Grinder (� Q
! F
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
l� ,r
Design Flow(min./required) y�d gpd Design flow provided d
Plan Date l t S� gp�
�� Number of Revision Date ,
j ,Title /4 ' �G7 /�.Z c%� /zlc.7 �i.f�g✓i��t
1 Size of Septic Tank /J0O Gp� Awhj ,-f Type of S.A.S.
Description of Soil 5" �h
Nature of Repairs or Alterations(Answer when applicable)?Uj
'Date last inspected:
Agreement: r
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar ;f��ealt
Sig /II„ Date
Application Approved by / Date
I
Application Disapproved C r v Date
for the following reasons
i
Permit No. Date Issued
————————————— ——————
THE COMMONWEALTH OF MASSACHUSETTS i
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE9FY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( 4-Kpgraded ( )
Abandoned( )by 1.irai�1/rJ/A
at 1) 11,e 411//r: has been constructed in accordance
/ / r�
with the provisions of Title 5 and the for Disposal System Construction Permit No. � ,
O-J �'� dated
r t) ��
Installer ��� 6U115 ef/o.i Designer s ��i r�ci•••,.,ay
t#bedrooms '` Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will fun�ctio_n.as designed.l� X�
Date I ' — Inspector
———— ———— ————————————————Y—) �-———— ——
r �
No. F
CJC/
� ee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
lwtgoal *PgteM Con trUctton Permit
Permission is hereby granted to Construct ( ) Repair Upgrade Abandon
System located at
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: Construction mus a co /p�lpetteed within three years of the date of thi e it
Date 7// / Approved by
J/ v
I
4/22/2021 ShowAsbuilt(1700x2800)
t
TOWN O,FpB�{AnR�VSTABLE
LOCATION �,Ta Sa,�/� /3a;, y�('� llf SEWAGEkp?et,7-5w
VILLAGE ASSESSOR'S MAP&PARCEL/$7110'
INSTALLERS NAME&PHONE NO._l, v rkYY/�IJ f Y.7>?• 1'to
SEPTIC TANK CAPACITY /.$ZVI 446 _
LEACFIIN0 FACILITY.(type) 39)3 tZI(size) !ya�X /GL Y.-y 9
NO.OF BEDR OMS
OWNER 1
PERMIT DATE: /,j•iG-0 7 COMPLIANCE DATE:
Separation Distance Between the: _
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f Feel
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feel of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY_aZ.6L1
iry rw� �• •.. nrrr
of ilk)I
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https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=187020&sq=1 1/1
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FROM :down cape engineering inc FAX NO. :150836213880 Nov. 26 2007 01:17PM P1
Town of Barnstable
Reaulatory Services
Th,amss F. Geiler,Director
Public Health DIVISiOn
gasp .
Tbomas McKean, Director
200 Main Street,Hy211111 s, MA 02601
Fax; SOS-790-63M
Office'
Installer & Desi_-aer'CeE9Ac2ti0m Form
Date:
1{ 2 [� rm,acge Permk& 0200%7- y61Assessor's MapTarcel
' Installer: d✓J l D /�
Destper: --�
Address: �/ r Address: c? D
on , ��G'B i./ wac issued a Pe-it to install a
(date) (last' ler)
septic System at 2- 5c v based on a design drawn by
(21d�'e5S)
���. •`' `'/k- dated U .�
(pe der)
I Gp1'�Lfy ,hat the Septic System referenced above WES installed substantaalh- according to
the design, whic)1 mad' ia-aciude minor approved cnaziges such as lateral rel.ocatian of the
distribution boa an&or septic tark.
I cenilN+ that the septic 4),stem referenced above was installed u*ith major changes (i.e.
create:than 10' lateral relocation of1he SAS or =N' %ertical relocationi of azy Component
of the septic System) but in accordance with Stale Local Regulations. Plan revision or
certified as-built by desi-ner to follow.
OF MqS
ARNE HC
OJAL.A CP
(ln er's SiLmature) CIVILCP
No. 30792
(Designer's Siznatu c) (Aff x DT M. 67's Stamp Her(,-)
PLEASE R.ETURX-' T BARNSTABLE I'1.7BLIC HEALT14 rmq ION. CERTIFICATE OF
C0114PL1,kNCE WILI. NOT BE ISSUED UNT1L D019 T}i1S FORM AND AS-RU1LT CARD ARE
ftE .EIS D BY THE B.4RNS'T,4BLE PUBLIC HEA T'II DIY1$10,'�. TI ANiC 1'DU_
._ .. .,♦ AA A.
SYSTEM PROFILE NOTES
TOP FNDN. AT EL. 38.6'
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) Route 28
1. DATUM IS APPROXIMATE NGVD
ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE LOCUS
WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS EXISTING F
33.0' MINIMUM .75' OF COVER OVER PRECAST F 2% SLOPE REQUIRED OVER SYSTEM
�A=35.3'±
RUN PIPE LEVEL3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ROa Of
.0 FOR FIRST 2'
2" DOUBLE WASHED PEASroNE 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNfTS TO BE AASHO Bump's `�Bey
15Q� i �.,
SEPTIC 30.75' OR GEOTEALE FABRIC H- 10
31.0' 10� GAS , 28.5'
eAFFLE 30.63' �� 30.46 5. PIPE JOINTS TO BE MADE WATERTIGHT.
28.0' 33' AT SIDES 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH Q
MIN. ( 2.5% SLOPE) �6- CRUSHED STONE OR MECHANICAL 2� 2.25' AT END MASS. ENVIRONMENTAL CODE TITLE V. d,
COMPACTION. (15.221 [21 80
$ o _26.0'
DEPTH OF FLOW = 4
�� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
TEE slzEs: BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
INLET DEPTH = 10" 3/4" TO 1 1/2" DOUBLE WASHED STONE L�
0*111
OUTLET DEPTH = 1'4'" ( 1 % SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. O BSc.
A=17' LEACHING 5 5' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION B=162' SEPTIC TANK 12 D BOX 3 FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP
OBTAINED FROM BOARD OF HEALTH. SCALE: 1" = 2,000't
k
10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION ASSESSORS MAP 187 PARCEL 20
BOTTOM TH-2 EL. 20.5' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO LOCUS IS WITHIN AP OVERLAY DISTRICT
COMMENCEMENT OF WORK.
LEGEND 62 00' 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
100.0 PROPOSED SPOT ELEVATION G, 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
o REMOVED 5' BENEATH AND AROUND THE PROPOSED
+100.00 EXISTING SPOT ELEVATION I'v LEACHING FACILITY.
100 PROPOSED CONTOUR �1e' �' 13. INSTALLER SHALL DETERMINE THE FEASIBILITY OF
CHANGING INTERIOR PLUMBING FOR SEWER LINE "B" TO
LOT 40
100 EXISTING CONTOUR ELEVATION SHOWN PRIOR TO INSTALLING ANY COMPONENT
18,896t SF
C.O. PROPOSED CLEAN OUT 0.4f AG
SYSTEM DESIGN:
CP EXISTING CESSPOOL TH =
•�`' GARBAGE DISPOSER IS NOT ALLOWED
T 1 h
DESIGN FLOW: 4 BEDROOMS ® 110 GPD 440 GPD
440 GPD DESIGN FLOW
SEPTIC TANK: 440 GPD (2) = 880
TEST HOLE LOGS CP "? USE A 1500 GAL. SEPTIC TANK
ENGINEER: DAVID FLAHERTY, R.S., SE2755 O o LEACHING:
WITNESS: DONNA MIORANDI, R.S. BENCH MARK - SLAB AT O �'� SIDES: 2 (40 + 10.3) 2 (.74) = 149 GPD
DATE: SEPTEMBER 28, °2007
GARAGE ELEV. = 31.2 coo `� BOTTOM 40 x 10.3 (.74) = 304 GPD
PERC. RATE _ < 2 MIN/INCH G c �' ^� �� TOTAL: 612 S.F. 453 GPD
CLASS I SOILS P# 11949 USE (5) "3050" INFILTRATORS IN A TRENCH CONFIGURATION
C.O. ^� SLEEVE SEWER WITH 2.25 STONE AT ENDS AND 3 AT SIDES
ELEV. ELEV. / O�
�� LINE WITHIN 10'
0" 33.0' ` 0" 31.0' / EXISTING 4 BR DWELLING OF WATER LINE.
A/E 2� TOP OF FNDN EL. 38.6'
APPROVED DATE BOARD OF HEALTH, MA
11 30.1
8" 10YR 4/1 32.3' W TITLE 5 SITE PLAN
A/E c� w U, U, CA
B LS / Uk a; OF
O
LS 17" 10YR 4/1 29.6' � WALK ONE � �y
"
10YR 5/$ F 132 SCUDDER BAY RD.
28 30.7 B C 00 3 C.o 9 G
(CENTERVILLE) BARNS:TABLE, MA
LS � I
" 10YR 5/8 , � S PREPARED FOR
c�
PERC C 36 28.0 90, BORTOLOTTI CONSTJ
MS Gs
ROBERT DOWLING -
C -122 60' =200. DATE: OCTOBER 5, 2007
2.5Y 7/3 GRAVEL
MS PARKING �- off 508-362-4541
�A OF AS fax 508 362-9880
ii
god ARNE
2.5Y 7/3 o H. �k o� ARNE H. ��G do Wn cape en gin eerin g, in c.
144" 21.0' 126" 20.5' Scudder Bay Circle OJALA o� o3LALA
Scale: 1"= 20' No.26 CI L Cl1//L ENGINEERS
NO GROUNDWATER ENCOUNTERED J� �.� OP �� / 2� LAND SURVEYORS
0 10 20 30 40 50 FEET s T `�` 939 Main Street - YARMOU THPOR T, MASS.
TE v H. OJALA, s SAL
DCE #07-234 07-234 BORTOLOTTI_DOWUNG.DWG (DDF)