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HomeMy WebLinkAbout0196 SCUDDER BAY CIRCLE - Health 196 SCUDDER BAY CIR CENTERVILLE A = 188 105 1"I 3 2 UPC 17534 No.2.153�COR RASTINOS.UN i t � Commonwealth of Massachusetts /88 r _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name / required for Centerville ✓ Ma _ 02632 4-9-2020 every page. Cityrrown Statei. .- 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. 'mp°'ta"t When filling out �A. Inspector Information forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address ,aa Centerville Ma 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 4-9-2020 nspe- s Signature Date sue- 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 �v Title 5 Official Inspection Form �• yl� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle V� Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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: J At time of inspection this system met all passing requirements. I recommend pumping of septic tank upon transfer and every 2-3 yrs there after for maintenance. This report can not predict the future performance under the same or increased usage. This report is not to be used for bedroom count determination as we are using info available to us at time of inspection from the Board of Health. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �v l? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (corl ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 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 196 Scudder Bay Circle v Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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) y ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �v 6,p Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =A6 � 196 Scudder Bay Circle v Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: According to as-built card system consists of a 1500 gallon septic tank d-box and 2 500 gallon leaching chambers Number of current residents: 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 Seasonaluse? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gpd)): Detail: 2018---219 gpd 2019----572.6 gpd ( house was checked for water leak by COMM H2O and nothing was found so Im asuming it was irrigation.) I did not enter the house so I can not verify no garbage disposal but this system is not designed for use with a disposal. Sump pump? ❑ Yes ❑ No Last date of occupancy: currently ocupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 41n Subsurface Sewage Disposal System Form Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 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 41� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 per as-built Sludge depth: 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. Tank could use pumping. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts 92. ipi Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box was functioning properly at time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �v ,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v— 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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 of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. CityFrown 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.): One chamber was opened and had about 1 ft of ilquid in it at time of inspection with no signs of failure. there were several irrigation lines in area of leach chamber cover. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � I> Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 lip" Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �v l Title 5 Official Inspection Form II, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every 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: 13 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: attached inspection report page 11 (attached from 2007). Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �v l? Title 5 Official Inspection Form II° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 196 Scudder Bay Circle Property Address Owner Wilkins information is Owner's Name required for Centerville Ma 02632 4-9-2020 every page. CityFrown 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 06/29/2007 16:00 911-775-5122 pw11ofIt OMCL4,L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBS)URFACE.SEWACE DISPOSAL SYMIN INSPFA 11 N FORM ..,: . PART C SYSTEM INFORMATION(miftuW) Propel Address: n r-/ /. AfIf owner. W111r R 1 I M!Y Dafir of bopectbs: — :2 8 911 EXAM C Suutwo water Cbeck caftan Sba low wells Esdmatad daptb to gmmd wades /3 feet PIe m iad cm(do*)d methods used to deternafae tits blSb pvmd water*AdAm Obtained ftm rystam dWp pleas on reoend--ff ebodod,dents of dWpt On revbmA' Obsaved sits(abodog bole-wft b 150 flee of SAS) �[amcked wkb bad Bond of fbl -C� Obeeked wkh toed exer4wrs.lnsesilers-{attach ) ✓ wexess.d USGS plsia: YW Now describe hear you entabHshed the>wlzk SrswA W81W dowdm: . Oeh as. a « ..e .f ms. /1 p p o $AS. air. v fir .►� i w •1 a rp.... r.�n �� A I.+�f s�� 4 1 w�+iYMa�a.aw ors wcua wauaua aw aaoc,awr6aiV wmass pYOYs•Ia4i iWi iI�! 'r%w» Weir ♦"tot a t T•M /v Iw ft 3' z ram' 17�,° .1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '< 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for . CENTERVILLE MA 02632 7-7-14 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information (7 When filling out 6 2 forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN rA cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name VQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 re' Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number - ; 1% . r1 B. Certification I certify that I have personally inspected the sewage disposal system at this address and thatatbe ` information reported below is true, accurate and complete as of the time of the inspection. The inspeAion was performed based on my training and experience in the proper function and mal tenance Von 90 sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1'$'q140 oaf" Title 5(310 CMR 16.000). The system: A ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-7-14 Inspector's gnature 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. (,a .�G L t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 e t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Cityrrown 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: ® 1 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: SYSTEM MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION 13) 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-3/13 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 G1 �' 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Cityrrown 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Citylrown 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•3/13 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 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A SEPTIC TANK D-BOX AND 2 500 GALLON CHAMBERS PER PREVIOUS INSPECTION REPORT DATED Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2012--------289 2013------237GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 7-7-2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2001 PER PREVIOUS INSPECTION REPORT DATED 6-28-07 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 10 INCHES 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: 1500 PER PREVIOUS REPORT VARYING/ LIGHT TO Sludge depth: MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every 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 Scum thickness LIGHT 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? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee,or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Citylrown 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.): BOX LEVEL NO LEAKAGE AT TIME OF INSPECTION .Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: VIEWED BY CAMERA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CHAMBERS WERE FUNCTIONING PROPERLY AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i _ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 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 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-14 every page. CityrFown 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: 13 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: SEE ATTACHED PREVIOUS PASSING REPORT PAGE 11 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 —_ I t<, - Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form, Subsurface S Disposal Sewage Dis g p System Form -Not of for Voluntary Assessments ents 196 SCUDDER BAY CIRC Property Address WOOD Owner Owner's Name information is CENTERVILLE required for MA 02632 7-7-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 / 06/29/2007 16:00 911-775-5122 PAGE 05 . _ Pe=e 30 of l t .• / OM9ALMPXMON FORM'—' � UNWARY SUMSURFACE SEWAGE Dist m1Y PORN • . . PAIMIC • SYSTEM MMMAIMON(Owafte Property Address: /06 5—Alin An CIKIv Owsert L•r , 7 Daborbspadoas r —0/ .u: �' .�.. ,i� •It �„�� , SJ=CH OF SEWAGE DUPOSAL SYSTEM hW4&•dWA etch savage disposal rysM ink des to at lout taro pam "pph4 lu&wb of baaeb=kL LocoLe'4 walls vAdda 100 fet.Leem wh"p me m w up*so"Ibs Jv B up 1 /7 , a ' s 6 as' Ale 06/29/2007 16:00 911-775-5122 PAGE 06 Pqp 11.of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AA�IIESSMENTS SUBUMACE.SEWAGE DISPOSAL SYSTEM 1NSPECTl6t4 FORM PART C f SYSTEM INFORMATION(mWoued) Propaq Addre:.: owaex: / w-I r Dee ofImpecdos: _ 8 -O7 S7Y8 BXAM . Sur6os waver heck over Sbdlow wells Esft and depth to pound man 13 feet Plase"cats(cbo*)A methods used to&arodae the lash W=W water efevbtbo: Obtekod tlm system dear place ou semd'-lfebed W dNb ofdeslp pW revbwed: Observed sift(d xubs popaty/obsm Wm bole.wltldn 150 he of 11AS) V cbs&W with load Bond of Imo: tbedced veldt!Dail atavatot:, (atte� ) • be Accessed USOS dessbeso-acplsio: You meat dmft hour you esnbUdod dye hdfh Srma skv dwada: colt Arier ova w .. t /1 go O O f •x or r fir i w •! a rrr«M ww �I a► �M As 11 To of Barn table Pa Department of Regulatory Services 1 NSA B Public �Iealti>< Division ��oy a�i� 200 Main Sheet,Hyanola MA 02601 Date Date Scheduled .TI'rna Fee Pd. ZOO o Soil Suitability Assessme1Zt.1F n r Sewage Disposal. Performed.By: E.7�l /A/V Witnessed By: -�..00ATION & GENEINFORMATION . Location Address 19 ' Scudder BayNERAL ' . Circle.. Owners Name ,Tames. E Mur h e. •. . , •,. Yr Jr. MA - � Andress Gretchen H.. Murphy 18 8/.10 5_ „ phy Assessor's Map/Parcel: � _ � ..Engineer's Namc Dstervill.e W' Barn, BSC.. Group, Inc'- NEW CONSTRUCTION REPAIR �r1 Telephone 508-778-8919. . Land Use RCS I (�- Aid•I �L t! Slopes(96) SurfaCasio as W Distances from: Open Water Bod ' ' y----_.__R .Posslble Wet Area I U ® — R• Drinking Waler Will 4ADrainage Way RR Propertj1'Line O —__fl Other------------- R. SKETCH;(Street name,dimensions of lot;exact locationsof test holes. ere tests. ands y o ha 1 locate well In proxlmil t {.^ • sa �.i Parent material(geologic) A�1-i W ASS N I �. Depllt to Bedrock_ Q 14 •� Deplh to Groundwater. Standing Water in Hole: Weeping(1•om Pit Pace Estimated Seasonal High Groundwater DETERMINATION FOR SEA ONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs,hole: In....Depth to soil molllust In Index Well N Reading Date: Index Well Icvel In. t7roundwaler AdJuslmenl 6• .., Ato,factor, ,r,,r Adj.Urouodwaler l.pvel,,,_ PrRCOLATION TEST. unite _ 'A7ute Observation Hole M r 3 IJ . Time at 4" - Depth of Pere �--�-- Time At 6" Stan Pre-soak Time Q ----- -r 'lime(9"-6") Bnd Pro-soak Rate MinJinch Z Site Suitability Assessment: Site Passers 1� Sit!Faild: ,+ ;Additional Testing Needed(YM) 1 . Original: Public Health DIVIsion ' ObsefVatyOn Hole Data To Be ComPteted on Bnek----------- ***If percolation test is to be conducted whisid"100' of wetland,you must first notify the. Barnstable Conseirvation Division at least one(1) week prior to beginning. WS EPTICIPER CPO R M.DOC DEEP.OBSERVATION HOIy�E LOG '. Hole# . 1 Depth from Soli Horizon Soil Texture Still Color • Soil• Other Surface(in.) (USDA) `, (Munsell) Mottling (Structure.Stones;Boulders. . i.. AIA ip 3 f ,�N'p'. a.s-Y 613 , i DEEP OBSERVATION HO 1✓ LOG Hole# a Depth from Soil Horizon Soil Texture Soil Color Soil Other )IJ Surface(in.) (USDA) (Munsell), Mottling (Structure,Stones,Boulders. a e d , � A-� YK 31.a' is B ` �v 1GYR yIG IoAt Y .JA�`G a 1 Ii i J DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon j Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Q -0L re c WbPA k)AtA S60\0 3`1 rah` G a M SAIAO' -;t. `( b 3 DEEP ORS .ERVATION I-IOI,E LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA). (Munsell) Mottling (Structure,Stones,Boulders. 0 - QL le A SANo V A V 0 YR �lj GAMY SkAD to YfL y D- 3o GI M- SANQ -7.s►� y fi t✓ '36 --tau C:a M F SAND a.Y `C 6 3 Flood Insurance hate Mom / Above 500 year flood boutdary No 1! yes Within 500 year boundary No yes V Within-100 year flood-bou dary No✓ .'y� �1 Aepth of Naturally Occurrine Pervious Material' Does at least four feet of naturaily occurring pervious material exist in all areas observed thrpughout the: r area proposed for the soil absorption system' Y CS If not,what Is the depth of naturally occurring pervldus material? CeC11flCallOn . I certifythat on .� (dale)I have passed the soil evaluator examination approved by(he . Department of Environmental Protection and that the above analysis was performed by me consistent with ;•.. .:;. E AN the required tr inin .expertis and ex erience described in)10 CMR 15.017. Signature Dam 7 U COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A CERTIFICATION Property Address: 6 SGLt oUt Owner's Name: OM .- Owner's Address: /96 S'c" er gabf Cir r., Cn ' Date of Inspection• E—2 f—0-7 �- Name of Inspector:(plgase print), Idin M• A? Company Name: Jot• a v Apc ; o Mailing Address: /92 Ul,u. .,kfi S r c Telephone Number. 5-0j-'12B --�e'79 _ CERTIFICATION STATEMENT h) M I certify that I have personally inspected the sewage disposal system at this address and that the 6ormation reported below is true,accurate and complete as of the time ofthe 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 CM .15.000). The system: t� Passes . Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: G��� Date: �—D7 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page 1 Page 2 of l l , OFFICIAL INSPECTION FORM-NCjT.I.FOR'VOLUNTARY-ASSESSN. S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 6—19—0 7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete aN 4Srl p- A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank faihne is immineaL System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance. indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout 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)art tcplaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS i SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART . CERTIFICATION- .(continued) Property Address: -94� $ckdaleAl Owner: 9114op jP,, a,.tv Date of Inspection: b 217-497 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther 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 1&303(1Mb)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ` The system has a septic tank and SAS and the SAS is.within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well**.Method.used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11. OFFICIAL INSPECTION FORM—NOT IFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION:.FORI., PART A , CERTIFICATION-(continued) Property Address: �9� �'�a+�e��r Crrel., C--n le vv,74 Owner: XJ, mt✓ Date of Inspection: g'--2 f—a,7 D. System Failure Criteria applicable to all systems:. z You must indicate"yes"or"no"to each of the following for M.0 inspections:- Yes No _ _t,' 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 t/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _t-1 Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow V 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. y' Any portion of a cesspool or privy is within 50 feet of a private water supply well. d/ Any portion of a cesspool or privy is less than 100 feet but greater than'30 feet from a private water supply well with no acceptable water quality analysis.[This system passes if theavell water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.j /m (Yes/No)The system fails.I have-determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to e n a 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface i water l — — Y �Y 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. 4 :- Page 5 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:^fir-B Sca4el ee &If 611e b Owner. W11 IJm'rn 7mie.I- Date of Inspection: 6 2 8—D:7 Check if the following have been done.You must indicate`yesr or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health r Were any of the system components pumped.out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as NIA _ .Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? 1/_ 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? V-' 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 jSAS)on the site has been determined based on: Yes no 1/�'_ Existing information.For example,a plan at the Board of Health. ' r/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)] 5 Page 6 of 1 I y OFFICIAL INSPECTION FORM—NOT FOR VOT,UNTAMY ASSESSMENT . SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ; Property Address: /96 56u J61-9r &3"P,� Owner: A H,yj�o-e.- Date of Inspection: —:18­p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: -- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): /vo [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): Ves Water meter readings,if available(last 2 years usage(gpd)): N .��r�h kl�ee s_ Sump pump(yes or no): Ala Last date of occupancy: oc-e- ,z.0 A/®— COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: X(OWh ¢ 614-vA e#- Was system pumped as part of the inspection(yes or no):_d& If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM L Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach'a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed'(if known)and source of information: tu fhS l2,� f/-o7-200/ �onj A2`,s'y,� f�ir�� iStazc9 �i1s TOtcir� Beer/ Were sewage odors detected when arriving at the site(yes or no):A/o 6 ..Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: /Ab • e-&-Flare ;ga Cvcly ce-itzrt'I'lle 9Y/A Owner:JL1f�iurh rri+' Date of Inspection• BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: oast iron 40 PVC other(explain): Distance from private water supply wen or ' e: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: /D' Material of construction: oncrete metal fiberglass polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of . certificate) Dimensions: 1.roo S7 Sludge depth: A%oHe e r ou 1<1f' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: psis a t©wtie f Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Afea rw,-,. r orA Comments(on pumping recommendations,inlet fid outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): -Pi*Mcl'JvaiKy cr1t T � GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT7 OR46LUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM; PARS'C. : r i SYSTEM INFORMATION(continued) ` Property Address: /96 S cld E'r &vy 5Wre7 vi 77.p Owner. yre.- Date of Inspection: G—Z 8—O7 TIGHT or HOLDING TANK: (tank must be pumped at time of m site plan) Depth below grade: _ Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity gallons Design Flow: gallons/.day Alarm present(yes or no): Alarm level: ' Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: t (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 yyou�r out of box,etc.): ./ //-- 60., - kn C7,Orvi4 - f� g ` PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition ofpumps and appurtenances,etc.x Page 9 of 11 OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /96 Sc',doe,& cj;d 0 Ce n er ye o Owner: i�U11,p.� 71,".e Date of Inspection: —!z S—o 7 , SOIL ABSORPTION SYSTEM(SAS): V (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number.' +� leaching chambers,number Z leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number inuovative/altemative system Type/name.of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 2=S"o©rf,1. GA /aa.r,s jize (w:W /3.�'}x�ony7� ZIs)X &14 2) ked /j/D 04• a.. v &~ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—to of liquid d to inlet P P 4 invert: Depth of solids layer: Depth of scum layer.• Dimensions of cesspool: Materials of construction: ' Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of pouding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: ' Dimension's• , Depth of solids- Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 'I o Page 10 of I 1 1;C,i.. OFFICIAL INSPECTION FORM'-' Nt 1R YOMN"I AY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SY0EM INSPECTION FORM PART:C J'• • SYSTEM INFORMATION(continued) Property Address: J176 5c_-JJPr Bcr CI�c1.- 7-7 ,-,./ i Owner: W,,A r417. •IL. ., ws'. .. • •.. �L.i',•. , • Date of Inspection: �� P SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. .F awn wate NIiusP e - 74, r I0• Papa 11 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Se u d d Qr r Ci rC Owner. ��i a.�, r'jw 4- Date of Inspection: SITE EXAM to - Surface water Check cellar Shallow wells Estimated depth to ground water 3 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed Observed site(abutting property/observation hole within 150 feet of SAS) _pC Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) V' Accessed USGS database-explain: You must describe how you established the high ground water elevation: j G�dh kr �nG i-DahP/P/ftia faM a-f S,A,�, /F- I�co 0 0 S,f7 S. ra 13, Cd� aK v �Y/,r �aav s`/^ `+K�� 'ter tc $• n 'fJ4Y27�arP /mar✓� i'S a Otsa'+C1 IA s�� �P�W4'!w 01701, 4 O v •• 67 S/�� 11 L TOWN OF BARNSTABLE �, LOCATION 1 61(a 12ud f--, 6AV C,r_ SEWAGE # 200 VILLAGEG4yi uJI['. I ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 21 a�A^ SEPTIC TANK CAPACITY /S—d 0 6 4 L. LEACHING FACILITY: (type) '6 d 6A C 0WAM6. (size)/3;X S X NO. OF BEDROOMS _ BUILDER OR OWNER C .'PERMITDATE: /d d I 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 LAIDIO 31 a04 '��� S ,. l6 No. ;;?-2 Fee Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppfication for Migaar 6pgtem Construction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. t9(r SX►L IPMP$16 C+'*Qvo Owne s e,Addre s an Tel.No. G rte two V�t 0,: n is Assessor's Map/Parcel `V0 4V ,e T® `&QJ Cl%l P �T �J►C. —c Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J• DOYLE lit Ali0t. 42 Canterbury Lana East Falmouth, MA 0203@ Type EPweili�nf ild Telephone: 5 0 S 54 0=2§14 No.of Bedrooms�� Lot Size�sq.ft. Garbage Grinder( ) Type of Building No. of Perso s Showers( ) Cafeteria(' ) Other Fixtures Design Flow `X30 gallons per day. Calculated daily flow gallons. Plan Date rZ . Zer 1 Number of sheets k Revision Date Title 5 fro Se J Size of Septic Tank Type of S.A.S. Description of Soil !` _ ' ' X 1 3.2 ')C z G Nature of Repairs or Alterations(Answer when applicable) 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 provisio f Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance his been i su d b this Board of He lth. 1 Signed Date la-AF-0/ Application Approved b Date -4f,Ze= e,7 Application Disapproved for the following reasons Permit No.O�G/� 23 Z- Date Issued -�j ''N Fee F i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es a iUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication f'br ,;Di.5pogaf *potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location"Address or Lot No. �q(o SC��DPI R- G�1Z Owne 's ame,Addre§s an Tel.No. Assessor's Map/Parcel 1 cb 9 \ p 5 -7 O 3 ob C>-j Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J. DOYLE & ASSOC, 42 Canterbury Lane East Falmeuth, MA 62536 ° - w Type of Building: Telephone: 508/540-2534 g, w&llin No.of Bedrooms� Lot Size sq.ft. Garbage Grinder( ) t1Y Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -33 0 gallons per day. Calculated daily flow gallons. Plan Date Og! \'Z Znb 1 Number of sheets Revision Date Title t=� !K Z,- t "FL Fo Size of Septic Tank \ Do uts S Type of S.A.S. c_AA T -�2 \ izynAA }g Description of Soil S �11T �c-N►�-1 s-o%L- L,, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system a" in accordance with the provisio f Title 5 of the Environmental Code and not to place the system'in operation until a Certifi- cate of Compliance has been i su d b�y this Board of Health. l " Signed C� Date Application Approved b� _ Date -1,6 Z,,O ®� Application Disapproved for the following reasons � Permit No.,, ���.� L'6 �` Date Issued \ —————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded ( ) Abandoned( )bye C. at ?y e , has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe dated,4!k �_ �ey f Installer Designer The issuance oi this .ermit shall not be construed as a guarantee that the syst-in will function as esigned. Date 11 r17 �Zy u I Inspector 7) �l >y ----------------------------------------------- No. �1C-s9�� rr Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS li5pooar *p$tem Conotructton Permit Permission is hereby granted to Construct( )Wee-, ( )Upgrade( )Abandon( ) / System located at I-' l�/lv Sc v�fG>'e6� dQ� .v. C��y�ryi!/ 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 must be completed within three years of the date of this p6init. Date: "` t r Approved by ' r +5a a -g­l"y f.= a; �'�"%' 'w.`�,'~, ,y�` r•' + { f'�' � u Ssb ','`.�j 'sy�_, ,'':.,ati''w.�"� ,b 87 }�('' a�'s rC�'T'" -t = aaa K�,°�•':�„- ; "Y-� F . ; � •`a�1y`Ylp ` �,a :' Y _ �• $ E.s�^ `rtY OM•�i � `.NV L.Ai 77,�,� '� { ""' 7. Y � x LOCATION,: SEWAG8 , O 6 7 VIL LAGE.;ti r���(�" P,- P 'ASSESSORS MAP INSTALLER'S NAME&PHONE NO: ll,� . SEPTIC TANK CAPACITY A00, 6 4 LEACHING'FACILITY: 2 �0 o w (type) 6/t t M rS. (size) N0. OF BEDROOMS_ . BUILDER OR OWNER C PERM: TTD;A t T,�,E If , DATE M-PLIANCE � aratSep , , onDistanceBetween . 7. the. Maximum Adjusted Groundwater Table to the Bottam::of Leaching Facility ` Feet:=}'+u, Pnel an on site o.'r w thin.200 fee of leachi ing Facility (tf any wells-exist ng facility) Edge of Wetland and Leaching Facility(If any Wetlands exist within 30Yfeet o.f:l'eaclung facility) Furnished by.: i Feet 77 ee 3 i r x t a Lv , F s 3' � M x'> yr. R lie 7.;..777 ��•: _ I_I�,.>.Washed tA:ush'ed. � .. _ ._ o . Av. `�. .F•s----1Sencb MdtA],53e�. Na:'or ss snr�c�— PROPOSED.S US. TRENCH SECTION .. :.. Na'ol:`500.Ca17ori;:�iiseeatY:L2amDafs':._ ... - .. - . IWO. � :I7g03d10: i 0 e 1 lip Zoning District Rd-1 Overlay—AP. v: . 9ugding Setbecim Side 81 Reer 10' Assessors Data: Map.188-105 .` t-:. � , 1 ltenotee 4ppra�ale,Casspool(Typf'' ' .. R�y .. ..... - 1Pillfem &Nancy Hilmar P':O:::Boa 3BO7 Propposee 1600 Calico.tanx a Plnebuist'NC 28974 .LO t 51. 17 JrM. Data: '.Zones C'& P" IMW Panell.R5001 001E D 17,359.f sq.l°t u� i Panel Revised` Julp 2, 1982 t, \ \.. .o!'_: Pmpdsed SAS.Yiench V \ 12. J�621i017 °cW Se Wage System Repair Plan 196 Scudder ."Ba Circle ,c Fall..= an 37S"a Cen tervllle, .Massa ch use t is Scala I"=PO' D54 00tober 12 W01 PncP?Md 87: Gf2APHIC SCALE SUJzbaa�-Aoyle end,:easae�ta9 •!2 Canterbwy Iaae,'E`.�Ilaoath, Yd 026,46 ces®pools f ll"sad/or-ve--pools .. m m ."Te/apboan,tiOB/b40- colony_sand-for.f8!" *n 2SS4 ER 24 gi F.bµndntlon: 1 h h .... iL .. I :.�.-..• (dwnbr:oerila'•Ydet.tLe � abuse®tde yea�r ..�� �. ... '�. .�n_.\i-o�'•:. _ � -_� ..... ,, ..- .. .- ,.,_ �Y:-...: ..� � ��� N0. DATE OESCIUPDQ'J�' � BY � �7' I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S. YOUR NAME/S: Lwa''::�90 BUSINESS YOUR HOME ADDRESS: / l SC! OQ� TELEPHONE # Home NAME �i7 736�G NAME OF CORPORATION: NAME OF NEW BUSINESS —,r7 --T TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO ry ADDRESS OF BUSINESS Y MAP/PARCEL NUMBER ;�f` — d (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. J 1. BUILDING CO ISSIO ER'S OFF CE This individ al h s n i�fI e f a y p rmit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATIOt` u hor e Signet ** RULES AND REGULATIONS, FAILURE TO MMENT : COMPL.Y MAY RESULT IN FINES. 0 d '1 2. BOARD OF ALTH This individual ha bee orm d of the permit requirements that pertain to this type of business. �r/1�n Authorized Signe COMMENTS: 3. CONSUMER AFFAIRS 10ENSING AUTHORITY) This individual h s Veen info ed of the licensing requirements that pertain to this type of business. 'Authorized Signatur COMMENTS: i 1 F 9i t . _... .. . � � � _ _ •� .. _ .I _. .. �� 1 �. y ,. - � �' .«. - � � - � � .� - �a «. r e = m .. .. _ � � 4 P .. � � � � 6 �. ,. i� .. r � ._ .. .. ,,, �� � ,. o �. � n ', � 4 } � _r c-..... _ � ,.. .. .. -�� e _ t _ � - t. . � F,�. _� .. I E Profile lie Se e S t ern oTS i�. 6 3c,'' t-n.� G�JEQ. pvjZTL � r+,(9<M C.o�n vsKCv�4's TOP FOUND. EL �` f 2� of 1/8" — 1/2" Peastone Total Trench Length z S� L : :• o �� wArEx ncHr coves __ o�ac - 314" 1-1/2" Washed C.rvshed Stone INV. EL. 2' I t FLOW LINE ° �.- © .� o c� o r� 10- MIN. o °o o :� aP TI'ench Width t 4" INV. EL 1z.Q, Z g i �tw. e" '.� In v .El. -- - o +"� o o �+ �' EL u•1 314 — 1-1/2" Washed Crvs ed Stone INV. EL. suMP 1z.G ' 10' MIN. 4' uan0 0�ni - - -- INV. EL No, of Trenches _I PROPOS.E'D S A. S. TRENCH SECTION INV. EL. No. of 500 Gallon Precast Chambers d C h d St ne - - 2 she rvs e a . nvS Nc�t> �A -`CZ �u-'4.0 Ez �'--t PRECAST REINFORCED CONCRETE ' - cWSTLAV1> 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK DISTRIBUTION BOX INSTALL ON A LEVEL BASE 1D0.00 MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15,226(2) MINIMUM WALL THICKNESS = 2" N80•53'10"E TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE MINIMUM INSIDE DIMENSION = 12" g4.34 OF THE SEPTIC TANK AND BE ON THE CENTERLINE OF THE OUTLET INVERTS SHALL BE EQUAL TO EACH i SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT „ MANHOLE. OTHER AND AT 2" MINIMUM BELOW INLET INVERT. c ; N80.53,10 THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX MORE THAN 3" ABOVE THE INVERT ELEVATION OF THE SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING OUTLET PIPE. THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION ; LINE INVERT AFTER ALL LINES .HAVE BEEN SEALED IN PLACE. , 1 INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE ; 15 — SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE AND NON-REFORMABLE MATERIAL PERMANENTLY FASTEND TO THE ;1 ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY UNE OR RECONSTRUCTING' THE LINOS UNTIL ALL INVETS ARE OF 1 ;V 30.8 COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE EQUAL ELEVATION, i 1 a, '`► 1 / y 0 S13 AS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT �� �O �O SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 . --4-- •-- ` Lot )c . ' V VVV Zoning District: Rd-1 THREE 20 MANHOLES WITH READILY REMOVABLE IMPERMEABLE i 1 1 Paved 11 1 ��16� 17392 � sq.ft. Otwrlay:AP COVERS OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS , � E�t�, 1 PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND ' Driveway o� I � � 1 �� Building Setbacks: THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE. , 1 Front 30 ___- ^- Side & Rear 10' - ` 1 Pa do 1 �o i w. 1 - 1 I p Assessors Da to: llfap 188-105 4 Denotes Approximate Cesspool (Typ) - 1z �� I E 1 s1. T Kllliam ,& Nancy Hilmer ` 1 I DvvMng �' I P O Box 3807 General Construction Notes i 1 15 F o Proposed 1500 Gallon Tank c�,� Pinehurst, NC 28374 l.' All the workmanship and materials shall conform to D.E.P. Title 5 and the Town of \� ` 1 ' I 16 r a Barnstable rules and regulations for the subsurface disposal of sewage. Lot , 51 17 � �� FEW Data: Zones HC� & "B» ao , �< �`' FIRM Panel 25001 0016 D 2. At least one access port over tank tees shall be accessible within 6 inches of finish grade, �� 17,353 .f sq.ft ;- o , �0 5�I ! Panel Revised.• July 2, 1992 with any remaining access ports brought to within 12 inches of finish grade. v, b Proposed SAS Trench Space 10' 3. All components of the sanitary system shall be capable of withstanding H-10 loading o 13 I L unless they are under or within 10 feet of drives or parking. H-20 loading shall be used under or within 10 feet of drives or parking unless noted. 4. The excavator/contractor shall verify the location of all site utilities prior to any excavation. 1�Pa` as 00 5. Sewer pipes shall be 4-inch Schedule 40 PVC laid at 0.02 slope. ` 152 15.00 6. An mason units used to bring covers to de shall be mortared in place. , c9� o ` �� �8.58 S80'S314 Y masonry g I 103.36 1 8.BS 425.DO 7. Finish grade shall have a minimum slope of 0.02 feet per foot. - N88V0 eO\E ` 18 ` 18 f .�-- - -�--_- 17 -- 13------- edge -------- ---------- --------------pe vas----- SOIL OBSERVATION DATA: S4 of 15 16 o a C1 _ - - t TEST DATE 10 1� O SOIL EVALUATOR DESIGN DATA: EXCAVATOP �� ' S- STRUCTUREti : - ,�, ,H� 3 __. 0 1 Sewage System Repair Plan 1 Prepared Fora PERC%RATE _ � Z,.-�t� ���� �a TYPE NO. BEDROOMS GARBAGE DISPOSAL All O • �µ�DESIGN FLOW '�Y, 1%o3 a ► - 3 %���� ��I" of"�s �►°� STEPHEf N 196 Scudder Ba Circl e >✓L, 1� 0 +>!�' sir ,c J. � In N " DOYLE 0 I I t No. 37559 �j-� s 9 Cen tervdlle, Massachusetts Cj l.j I �oyR t, SEPTIC TANK L+tsc= 1Stn Lr-A�I.Ot�� 1 Rt^cGld�� _ __�---- ---- LA fsS � ! ISJ E'er t� '�� � E Scale: I" = 20' Date: October 12, 2001 G �� LEACHING FACILITY �t-3•Y �-s•z 4-cS'* y- `z D 15�L ' p 3'' Note: SCALE! 1b yo t Stephen d. Doyle And Assoeia tes s�zy -z.�•1 ,4�, I-s.-�,� -&�—- �o Pump extsttng cesspools ME and/or remove cesspools GRAPHIC SCALE 1 V. o. �_ � G � � �� . ,F�o 42 Canterbury Lane, E. Falmouth, �A 02536 kez Y c n va` s y�.l w Use only clean course sand for fill 20 0 �0 20 40 90 Telephone: 508/540-2534 f ' IN �'r ) I3Z 1 inch = 20 it, BM Top Ensting Foundation 15J�• - t�\o \I��� R. Datum: NGVD .... . ag YS srbe b cerdt�r that the altrrac shown an the plan ss thep NO. DATE DESCRIP77ON BY Lead srrrro�ur