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HomeMy WebLinkAbout0011 SHANNON WAY - Health 11 Shannon Vila Centerville A = 170 - 182 5 M E A D No.2-153LOR UPC 12534 #nwsd-aom • Made In USA 1 r n81 USA N iFlS ilOOU[�OE SFI OFMSFINArAM CERTIRED SOURGNG WWWSFPRRDGRAKO* TOWN OF BARNSTABLE '�OCATION i C �ifp,�5 W SEWAGE# VILLAGE_� �r1_tJI 1..���- ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. rG. _15_6 V-7-7(—C1,31 SEPTIC TANK CAPACITY �• Y LEACHING FACILITY: (type) NO.OF BEDROOMS OWNERititaf�-`� PERMIT DATE: COMPLIANCE DATE: C1-;t3 (5- 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 1 a 30 B-3 O 13 ;.. Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for 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:when A. Inspector Information c� filling out forms p on the computer, Michael DiBuono use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Ln Company Address Cotuit, Ma 02635 City/Town State Zip Code 508-364-9587 S113522 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 10/19/20 I pector'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 Farm: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 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for 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: The system is functioning as designed. 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 Title 5 Official Inspection Form ^ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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 ❑ 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 j Commonwealth of Massachusetts F Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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)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 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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 Y2 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 Forth:Subsurface Sewage Disposal System-Page 5 of 18 IL Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for every page. Cityrrown 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? ❑ ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 page. Citylrown 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: 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 228 Gpd 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 page. Cityrrown 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 i3Other(describe below): 3. Pumping Records: Source of information: Pumped 2017 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 c Commonwealth of Massachusetts UTitle 5 Official Inspection Form �;} Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 page. Cityfrown 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: 9/22/86 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .� 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" 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 30" How were dimensions determined? Tape Measure/Data On File Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 11 Shannon Way Property Address PATTEN, TIMOTHY K&GALL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•i 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for every page. City/Town 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 NA 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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: 1 ❑ leaching chambers number: ❑ 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for every _ page. Citylrown 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.): Leach pit has app 32"of seperation to the invert 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth bf solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Assessing As-Built Cards https://town.bamstable.ma.us/Departments/Assessing/Property_Valu... TOWN OF BARNSTABLE LOCATION I 1 1` Qk.11 SEWAGE*` J\61 V'-,34-# VILLAGE - A SSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. Z-C.t; 54. ' 711-13W SEPTIC TANK.CAPACITY _. LEACHING FACILITY:(type) t (� NO.OF BEDROOMS OWNER PERMIT DATE:_ . -- '�'� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater'Table,to the Bottom of Leaching Facility Fee Private Water Supply Well Leaching Facility(If any wells exist on site or within 200.feet of leaching facility)' _Feet Edge of Welland and Lceching:Facility(If any wetlands exist within 300 feetof leaching.facility): Feel FURNISHED BY 0 30 3tl 1 of 1 10/19/2020, 12:51 PM c Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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 Forth:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is required for every Centerville Ma 02632 10/16/20 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: 10+ 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: 9/22/86 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: Test hole data on file 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 Assessing As-Built Cards https://town.bamstable.ma.us/Departments/Assessing/Property_Valu... ( TOWN OF$ARNSTADU LOCATION. 0&1 SEWAGE#' i VILLAGE 9L.L,,g- ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. 77 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO.OF BEDROOMS OWNER PERMIT DATE: -a �'� COMPLIANCE DATE: 9,a3-('S: Separation Distance Between the: Maximum Adjusted Groundwater Table.to the Bottom of Leaching Facility Fee Private Water Supply Well;and Leaching Facility(If any wells exist on site or within 200 feetof leaching facility) Feel Edgeof Wetland`anil Leaching:Paciliry(lf any`wetlands exist within 300_feet of:leaching.facility) Peet FURNISHED BY it 6 I 30 01 - ` J-4 r 4.3 �t-�- B-3 3+' . 0 3 1 of 1 10/19/2020, 1:02 PM Commonwealth of Massachusetts p Title 5 Official Inspection Form ^i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 11 Shannon Way Property Address PATTEN, TIMOTHY K&GAIL E Owner Owner's Name information is Centerville Ma 02632 10/16/20 required for every 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. v �m ��4 t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLation for Misposal 6pstrm Construction 3permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System ZIIndividual Components Location Address or Lot No.// Owner's Name,Address,and Tel.No. 66-8-')'74';>OV Assessor's Map/Parcel/GCS 1 g­,),_ � Dab-r ertn � 5 Anne (�t Installer's Name,Address,and Tel.1No. gpd•yag-gqa� Designer's Name,Address,and Tel.No. itJIA �v(� : �' nSf� can c• Avg a3ox `70yxjars ,D GO-K Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4- cK, 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 Environm de and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signed Date q/(0(�- Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued '. -No. aG' �+ t Fee THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes —2ppYicatlon for bispoBaY �&pstem Construction Permit Application for a Permit to Construct( ), Repair O Upgrade( ) Abandon( ) ❑Complete System ZIIndividual Components Location Address or Lot No.// � �h p� �� lu./ Owner's Name,Address,and Tel.No. 3�8-?'?G-�Zo<!S 'C�en oeborc k l(enn ey /o aveers Ann, C Assessor's Map/Parcel/')v 1 Fig ,{-­�+ LIA 62. 35" IInstaller's Name,Address,and Tel.No. b ya Designer's Name,Address,and Tel.No. 1A-)1R Gr4r_)L �Ur�St rvG�jCN� lc • 10•U,o3rx `�U� �,c�x c��/� rsions C [p Type of Building: Dwelling No.of Bedrooms l Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) _ Other Fixtures Design Flow(min.required) N gpd Design flow provided t I gpd" Plan Date Number of sheets Revision Date Title .. Size of Septic Tank Type of S.A.S. V Description of Soil Nature of Repairs or Alterations(Answer when applicable) _`liar r c'L S'� )A ht,e 1'f Cr>-, �yl x Cx x A,,,E 5 ( 1 Date last inspected: 4 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposalxsystem in accordance with the provisions of Title 5 of the Environme to de and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt ' Signed Date q Application Approved by Date �J Application Disapproved by Date for the following reasons Permit No. a 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( )by 1?S 0 r` 0\0 6LA_ C�c�,,s��1�Ci Cn�t ::Er1C. - at I S hCun n U t'-, Le ICI> I_ CPr��C.U; ( Ic has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.es701-f-V4 dated Installer l��L�C �r�\G�.�ti l Gr��S/ /.�c,C CII'1 �hC Designer ► f/� ��}} #bedrooms Approved design flow gpd The issuance o this ,ermit shall not be construed as a guarantee that the system wilrfunWo l as deli, ed. Date Inspector -------- ---------------------------------------------------- ------ - ------------------------------------------=---------------- No.jo l .5 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(j(/ Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co ction must be c mpleted within three years of the date of this permit. Date Approved b pP Y i AsBuilt Page 1 of 1 ` SE Ste'S MAP NO. PARCEL. LOCATION SEWACE PERMIT N0. VILLACE r INST A LIES NAME ADDRESS II U I L D E R OR OWNER A� �A/ I Av DATE PERMIT ISSUED 9f _ �- DATE COMPLIANCE ISSUED - z �f as http://issgl2/intranet/propdata/prebuilt.aspx?mappar=170182&seq=1 9/23/2015 ` f} * l No.Aa..---��� ! Fxs. ............... THE COMMONWEALTH OF MASSACHUSETTS B®AR® L HEA T \Pj 10��..................OF...........................................-•----.............-•---••--•----•.--••-•-•---- S` k- Appliration for DwPogal Works Tongtrurtion Urrutit Appli •on is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System a .. --------------------- ....... !!... . ............. ---- ---- ..----•-••---- J ation- dress - Lot r -- ..................... ....... ....------............................. er I� Address Installer Address �-- Q Type of Building Size Lot...�.:�._r. Sq. feet U Dwelling—No. of Bedrooms......-3.............. .....Expansion Attic ( Q Garbage Grinder ( 4�0 C pa Other—Type of Building ___________________-_.____• No. of persons............................ Showers ( ) — Cafeteria ( ) a Q' Other 6xtures ............................... .. - •-•-----•--•----------••--•-•---------------------- --•------------------------- W Design Flow.......... ... ..................gallons per person per day. Total daily flow.._....�e. .�J...................._gallons. 1:4 Septic Tank—Liquid capacit4 -gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area------------.-------sq. ft. Seepage Pit No-----(4.*-.a. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water....................... (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ----------------------------------------------------------------•-•------------------•--•-•--.---_.......................................................... 0 Description of Soil.................................................................................................................................................................... x V ------•---••••---------••-•-----------•--•-•-••--••-----•----•---------------------------•---•-••...............••-•-•----------....-•----•-•-------•-...---••--••--••••-••-•...............-•••----•--- W V Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•---------------------•------••------------------•--•-----------•-•-•--•-------------------------------------------------•------•-•-----•-----•-•-•---•-••-•--••---•-•-•-•••-----.......•-----•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L i s.% p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a ifica !EtCompliance has been is d by the boar I th. Si ned• -........ �� D Application Approved BY -... .. ............•--------••--•---------.:....... � ate Application Disapproved for the following reasons:-------•-------------------------------------------------------------•----------------------••-•......----•-_.. --------------------------------------------•-------------------------------------•----•-----......-•---••--------..........--•-••••------•••---•-•---••---••--•---•----•------••..........---••--•----. Date Permit No.-- ------- --- Issued....................................................... Date No� � ►'tr Fps . ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD FOF HEA T•,H ........ .........OF....1� ........ , ppliration for Diopo,sttl Works Tonotrnrtiort Prrutit Application is hereby made for a Permit to Construct (11, or Repair ( ) an Individual Sewage Disposal System at` Z r �..---------------------------- -- .........._.. ...--'' -----=.,location; ddress � "� � �•' or Lot No. / ..£...._ "Z•._.T'�'2 f: °"�i ..� ?Svdi�. .._4.0........................ .........�*L,II}...T .. S !.'"` F •S. .._ .. ......................................... %J .Owner r Address nstaller........................................' .__.^. _ ..___. _._...�'��...___•___.._.________......._...._....___._..._....___ � I Address •�""' d Type of Building Size Lot_....:!�...7,A �.Sq. feet aDwelling—No. of Bedrooms....._s...................................Expansion Attic Garbage Grinder QI Other—Type of Building ............................ No. of persons...............,.._..------- Showers ( ) — Cafeteria ( ) a Other fixtures d -----------------------•--------------------------•-•-------....--••••-------.••••••-•--•-••--••------------•-•------•-....--•----•-------•--------- W ow.......�'+Design Flow ........................gallons per person per day. Total daily flow........ ..' - �.��. ................gallons. WSeptic Tank—Liquid capacity^-l:........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.... =__. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ W 1 P P P ground,..a Test Pit :�o. 1................minutes per inch Depth of Test Pit......____....._____ Depth to water..___._______.________.. fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•-----------------------------•-----•-•-•----------------------------•--••-----------•------------------------------------------------- •-------- 0 Description of Soil.......................-................................................................................................................................................ W V .............•-••-•-•-•-----...•-•--•-•.............••------•-••-------------•--•----••-•----------•......-----••-••--•---------••......------•...................................................- W ------------------------------ ----------------------------------------------------------•------------•-----------..........----------•----------....-----------------------------------------..._...... V Nature of Repairs or Alterations—Answer when applicable................................................ .............................................. -----------------------------------------------------------•------------------------•--••---........----•-----------------------------------•-......------------------------------ ......--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r,-mg u the provisions of 1 T:_., r}of the State Sanitary Code— The undersigned f titer agrees not to place the system in operation�untill �11ica • Compliance has been issued by the boayd^of health _� Application Approved By.........� ......... ......... .............. ��2-d/ ....-------- •1Date Application Disapproved for the following reasons:---•----•-------•-•------------•---------••--------------•-•--•-------------------------•---•-•------•:...---•-- r....-, Date Permit No..........c-....------------ .6, ,i---... Issued-------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH ..........................I........OF..................................................................................... Trrtifirtttr of Toutpfianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (\-/or Repaired ( } by ----------- •----------•-------------:---••------.--------..----•--------- --------------- e- Installer has been instailed in accordance with the provisions of iIT j of The State Sanitary Code s describ in the . / —" r� . application for Disposal Works Construction Permit No._�; _._.._ .__ da.ted_._.. •. __L��..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT YHE SYSTEM WILL F �19N SATISFACTORY. �•�— PATE.............e42 ................................................ Inspector-•- d-----------------------...----••----•-------------..._-----------.•---•- THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH Ya , �/ ....-...�......cn,>,�...... .......... .OF......... ................................ .lam )j,D-r FEE---- ..__ ....--- Diopooa1 Works Tottotrur#ion rnmit Permission is hereby granted•.._ ........... to Construct—(--) or Repair ( _)_an. kidividu -Sevts ge P i posal Sy MT" _... - --- Street as shown on the application for Disposal Works Construction Permit Dated.._ A-G ---------------------- / -i...= --------------------------•-= Board of Health DATE.- - ~�� rTµ~ ...................................... a .. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS __„ ' I -�. - If j, �7 773 S EPn TT'RrJ�C33DLn�sa,�s:g95C�P� sZL, T U��s ibara Gca.iJ o►.i'S�pii�► ,,K 1D 0 f u �15'POSAI.�:fT G SE LCt�A;- h1:1.04 rr 3'-lA4x o 67 r"tt7acr i-l'sosF,C2s=-i I 3Zs� _ - ' �- 01A OF CaQ�c.cl•(�`Wst=;�. l.o _ ... :sa. C�Pa . . it6c1J t- w:t. 425 Ex?V t PETERLLI 9 N{ ToSULLIVA -tA DAJ No- 29733 >, �t >r,l~Cai;1�.TlalJ TC 1'P�t?Pt►.1ZM��l.0QLtiD55 �10 -F ARD -a ,t3AXT.E Tr-ST 't 41 E3 G o q �75` .� 5' ¢ �G► Toy 01 FI;117 .0 _ . _ . c � INA 4 ��� �f Sgpr\c ` 1 3q,ol5x C >✓RTIFI ED pLZDT P1.q>,4 S77µE EL q�.q.- 1.OcATIaN:C ►?NTERYIt�t.0 h'� $ �v61ts 3 Tc��c/IJ t7F�A '0�$LE `��iJI� is 'NCB' _/4�-IC�t�IT: ��> �N �M h t�►.� E3' ,t l�aGra`�2''W 7F1.aL�?'F�LAt This R.Ati 15 NZ $AStR DNAN INSTRtJMNT 5WKIeEY r,No THE:H OFFSETS 5fIoWN 5HZX4L-D TqoT ru� r3 E uSE�r Ta EST'Pt'�3L15N La-(' �l NE 5. : GUIOE LINE �. 1O X 1O TO.THE If.CH: Postal7 U.S. � Mail Only; surance Coverage Provided) (Domestic m 0 For delivery information visit our website at www.usps.com6 I OFFICIAL USE M Postage $ O Certified Fee 0 Retum Receipt Fee a Postmark 0 (Endorsement Required) `7TMere O �- Restricted Delivery Fee err N (Endorsement Required) MTotal Postage&Fees $ _ O Virginia M. MCNeil Trust l.p % Mr. & Mrs. J.C. Lundy o r j 11 Shannon Way !�_ Canl rv� ille. MA_02632 Certified Mail Provides: ■ lieA mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mails or Priority Mail: ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the. fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate"return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the j endorsement"Restricted-Detivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONSENDER-COMPLETE THIS SECTION ' COMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete M - item 4 if Restricted Delivery is desired. O Agent ■ Print your name and address on the reverse ..1 ✓V'', ❑Addressee so that we can return the card to you. V. F4ceived by(Pdnte Name ff C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. kA delivery a;d7 s Siff' t' �' m 1? ❑Yes 1. Article Addressed to: '► YES,entYl' ry addles ❑No m Virginia M. McNeil Trust _11�? o i I % Mr. & Mrs. J.C. Lundy 3. Service Type )►j:3 11 Shannon Way ❑Certified,Mail® riorityMailExpress. Centerville, MA 02632 ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number �— �-- —z— I (Gansfer from service labeg 7 014 12 0 0 0 b 01 0 3 5 8 0 3 5 2 PS Form 3811,July 2013 Domestic Return Receipt. 'PVT UNITED STAT'E"Ei��P TAL-§ A IhT-MffbM.M-aT— �ROM§g d -'wLt' • Sender: Please print your name, address, and ZIP+4®in this boxo Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 IAIVI 1,11,101 M Town of Barnstable Barnstable Regulatory Services Department MASSPublic Health Division I 0,19. 1 200 Main Street, Hyannis MA 02601 200� Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7014 1200 0001 2851 0352 January 19, 2015 Virginia M. McNeil Trust % Mr. & Mrs. J.C. Lundy 11 Shannon Way Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 11 Shannon Way, Centerville, MA was last inspected on 12/14/2014 by Trevor Kellett, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00). • The septic tank has a hole in the side of the outlet at end of tank; a former outlet pipe opening needs to be repaired .� The Distribution box is corroded and crumbling; needs to be replaced You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH BOARD OF HEALTH o s cKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future EAU I Shannon Way Cent Jan 2015.doc � € T Parcel Detail �� .�, .. ,� x C. D issgl2/inhanet,rpropdat,a;,,pai-(P,,!D fiil,aspx?ID=Il4'04 I !j a i µ Parcel Info 50, . Parcel ID 170.162 Developer Lot LOT 681 , Location 111 SHANNON WAY _ Pri Frontage 174 Sec Road SETH PARKER ROAD sec Frontage 89 Village CENTERVILLE Fire District C-O-MM _w Town seweresists atthis address NO Road Index �2149 Asbuilt Septic Scan; { Interactive Map ( Ok � � s 170182 1 " t , d `Owner Info Co• Owner'LUNDY,J C&VITA,V M owner VIRGINIA M MCNEIL TR I streetl 11 SHANNON WAY street2 city CENTERVILLE state MA Zip 026322 country r Land Info S;. w i w Acres 0.41 use Single Fam MDL-01 Zoning RC Nghbd 0106 f Topography Level RoadPaved utilities Septic,Gas,Publlc Watel Location t, 3 Oonstruclion Info ` , z Z_ k Start SEPTIC Letters Se ti, Parcel Detail-Goo le Ch,,,` � #fl 1 1.01 PM 4 { e 9 -�d:'a 1 �., ,.�., s I�^4 d�,.' -,� i �.,_ ,?� G�+;��.r Nw?'k. a� ®, ' _.� Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NT (5.1) Oxlw3 toommonweann OT massamusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owners Name information is required for every Centerville MA 02632 12/14/14 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: 3 key to move your cursor-do not Trevor Kellett - — use the return Name of Inspector key. Co Septic � Company Name 38 Vacation Lane Company Address West Yarmouth ma 02673 City/Town State Zip Code 5085795502 S113744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority XJL�4— 12/17/14 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. t5ins•3/13 Title 5 Official Inspe ' n rm:Subsurface Sewage Disposal System•Page 1 of 17 %,ommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 .12/14/14 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete ail'of.Section D A) System Passes: I ❑ l'have.,n©t-ifoun:d.-any iriformation which indicates that any of the failure criteria described im310 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 orrrepair, 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): The septic tank has a hole in the side of the outlet end of the tank, a former outlet pipe opening needs to be patched t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 uommonweann or massacnusens Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. City/Town 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 higt 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): D box at water line is corroded down to bottom and crumbling needs repairing or possibly replacement, TBD by installer ❑ '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): ❑l 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 t5ipp-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 \ toommonweann or massacnuseris ' s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 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 4surface 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 Vommonweann or massacnusens Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. Cityrrown 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. P ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. i ❑ ®. 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 Forth:Subsurface Sewage Disposal System•Page 5 of 17 t ommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 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 6ommonweann or massacnuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owners Name information is Centerville MA 02632 12/14/14 required for every page. City/Town 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? (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: Sump pump? ❑ Yes ® No Last date of occupancy: ,; 1/1/13 Date Commercial/Industrial Flow Conditions: 't 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 \ Loommonweann oT massacnuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Shannon Way Property Address Virginia McNeil Trust Owner. Owner's Name information is required for every Centerville MA 02632 12/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 uommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 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: 10/04/86 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 g Sludge depth: 1" t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 \ itommonweam or massacnuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 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 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 911 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Hole near out pipe needs repair both tees intact,the tank does not require pumping 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 L\ q.,ommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ;.❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 \ itoommonweann or massacnusens Title 5 Official. Inspection form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owners Name information is required for every Centerville MA 02632 12/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The d box is level how ever is corroded and crumbling no 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.): * 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: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 ltpommonweann W massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 M , 11 Shannon Way . Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching.galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This 6x6 leaching pit was dry with a stain about 8" up no ponding or staining in the soil 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•3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 J toommonweann or massacnusens . Title 5 Official Inspection. Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 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 #.,ommonweann or massacnusens 4 Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form-Not'for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A i Aa131A A�S)14a 3).� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 tommonweann or massacnusens r Title 5 Official Inspection: Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 5 feet Estimated depth to high ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS shows ground water at 50 feet 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 l.ommonweann OT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Shannon Way Property Address Virginia McNeil Trust Owner Owner's Name information is required for every Centerville MA 02632 12/14/14 page. Cityrrown 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 Forth:Subsurface Sewage Disposal System•Page 17 of 17 (7, 'S MAP NO. PARCEL � [t0CATION °SEWAGE PERMIT NO. VILLAGE fA J �Tll �� � q;v?lf INSTA LLE NAME J ADDRESS Al S U I L D E R OR OWNER A A A) DATE PERMIT ISSUED _ DATE COMPLIANCE ISSUED . r` 4 i