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HomeMy WebLinkAbout0014 SHANNON WAY - Health ,2 14 Shannon Way Centerville A= 170-181 No. 4210 1/3 ORA Pendaflex 100 F r Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' �> 14 Shannon Way..Centerville..MA P. �roperty Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name / information is required for every Centerville r/ MA 02632 1/20/2020 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 th-e fo.rm,. Important:When filling out forms A. Inspector Information on the computer, use only the tab Armando Pantoja key to move your Name of Inspector cursor-do not Ar_.r_.tt SPnr_.hpr_.k use the return key. Company Name 17 Northside-Drive rah Company Address South Dennis MA 02660 City/Town State Zip Code 508-385-5891 SI 14296 Telephone Number License Number LJ. CUr U I KOUtivi i 1 certify t.h-f•1 am a-DE-P annrnypra avatnm incrnecter in hall compliance with Section 15.340 of Title..5 (310 CMR 1'S`.000); i 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. I -1 Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note; Thiq rennrt.only efegcrihec rnnditinns at the time of incner__tinn and nndpr 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 M Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way..Centerville..MA rioNm by nduicaa Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary 'inspection Summary: Complete 1. 2.3, or 5 and aii 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: 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, N or the following statements. If"not determined," please explain. A? The septic tank is metal and over 20 years old* Gr` ie Septic tank(- i Tether metal or not% is structurally unsound, exhibits substantial infiltration or exfil tion or tank failure is imminent. System will pass inspection if the existing tank is replaced wit complying septic tank as approved by the Board of Health. *A metal septic tank will pass insp ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the t is less than 20 years old is available. ❑ 'r jJ iv Lu 'NO (Expialo beiuw)- t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts M Title 5 Official Inspection Form 1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Wav, Centerville. MA F1— y nddieSS Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 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 le in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or u ven 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 removedAP Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND (Explain below): ❑ The syste/okenpipe(s) pumpinq more than 4 times a year due to broken or obstructed pipe(s). The a.... ♦ .. F i...at 1 i the o,.,.d E u,...u� SyStcnf wpection if (eaiuf approval in he Boa+u of Health): ❑ b are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Bof Heal ❑ Conditions exist which require further a alI� by the Board of Health in order to determine if the system is failing to protect public heal safety or the environment. a. Systeil1 will Wass unieSs Boar' f riealthil determines ill accordance with 310i NIR 15.303(1)(b)that the system i of functioning in a manner which will protect public health, safety and the environme . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >r� 14 Shannon Way. Centerville. MA rl.......— A.J.1....... rl VFJCI Ly MUU,ass Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) iii 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 pplier, if any) determines that the system is functioning in a manner that pr cts the public health, safety and environment: [,I Thp system has a septic tank and coil absorption syst (SAS) and the SAS is within_ i 00 feet of a surface water supply or tributary to a surf a water suppiy. ❑ The system has a septic tank and SAS and the AS is within a Zone 1 of a public water supply. AV ❑ The system has a septic tank and SAS a the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S S and the SAS is less than 100 feet but 50 feet or more from a private water supply we Wthnri /t.spri to fipfprminp riistanr . ** This system passes if the w I water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates sent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro lded that no other failure criteria are triggered. A copy of the analysis must be attached to this fo 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 Rnn..klrn of sawana intn fanility nr svetam enmrnrinant(lira to nvarinoriart nr clogged 5A5 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 r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way..Centerville. MA n.....,.— n..�....,.. ri ILY MUUIc0a Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Fanure Criteria Agglicable 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 niimninn mnrp than d timpc in the last upar NnTrinp to ninnnpri nr I IXI :_y �...� ..._._ _.._. ... _.._ , - - as-- - 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. I I IXI Any portion of a cPssnool or nr vv is within 50 feet of a nrivate water sunniv 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 custodv must be attached to this>rorm.i ❑ ® 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 a following, in addition to the questions in Section CA. Yes No Af ❑ tha system is within 400 -et of a surface drinking water Sunnlu wrry ❑ ❑ the syst/200 feet of a tributary to a surface drinking water supply ❑ ❑ the syst in a nitrogen sensitive area (Interim Wellhead Protection Area- apped 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 f Commonwealth of Massachusetts M Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -: :- 14 Shannon Way,.,Centerville,.;MA Hoperiy Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If vCtj`have answered "ves"to any gitesfion in Sertinn C,5 the system'is r_nnSiderQd a siconifirant 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? I IXI Have-1a,rge%vialum e:?y,afwater,hon4ntrcarir�ced to the S� m stpranpntly-or.as.pa,rt.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? P -N IU Were all system components, Px ,_._inn thc? SAS,_located on ¢it-. ® ❑ 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 locaticr.to the S^il A-k. ^rr%tioh System ISAS) On the clte has Hear v�Na v:. wy.. \\+ / v�l '1'1'v 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 f.n 14 Shannon Way, Centerville, MA Property Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 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): 330GPD Description: 1000 G SEPTIC TANK DBOX AND 6'X6' I EACHING PIT WITH >_!' STONE Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ZL\j No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 402 GIRD 9 ( y g (gp ))� Detail: 2018: 170,000 GAL, 2019: 124,000 GAL Sump pump? ❑ Yes ® No Last date of occupancy: 2020 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 14 Shannon Way, Centerville, MA n........ n aa..,.... Pr uFrcr ty-nuuress Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date f 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 pres t? ❑ Yes ❑ No Nnn-sanitary wastg clLscharne tg_the T4W 5 system? ❑ Yes ❑ NO Water meter readings, if ailable: Last date of occupan /use: Date Other(describe elow): 3. Pumping Records: Source of information: PUMPED 2016 PER OWNER INFO 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Wav,-Centerville, MA rrop�y Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 'Tvne of system: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool f l Prlvv ❑ 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 11 'tight tank._;Attac nnv of the bFP.annrclygj ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: SEPTIC-TANK AND LEACHING C:HING PIT ARF 34 YFARS r11 Il. CYCTFM 1[VCTAI I FD 1986. NEW DBOX INSTALLED 2014. PER B.H.D. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2-3 feet RAatprinl of rnnctnirtinn- ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAIvaGEE. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way. Centerville. MA n._.....y t n.._..,.". FI VI.ICI -InVVECda Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site Mani: Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years i_ r._.Y_.� '.._- i._..a r.__i_ i._.v._k '....n i -� r__."a r__a._� r-1 v.__- 1—I sk_ Is age conlll�l-l-ICU.FJy G LGI hicate UI liVlll�.Jlldlll:e! �dlldlaI d l:Upy U1 CelLilica C) I__I ICJ I__I 114U Dimensions: 8'X6'X5' 1000G 81, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 26" SCurn Thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? CORETAKER Comments (on.pumping recommendations, inlet and outlet tee or baffle condition; structural integrity. Hqulld levels as related to outlet invert, evidence of leakage, e[L.). PUMPING RECOMMENDED. INLET PVC, OUTLET PVC. 48" LIQUID LEVEL AT OUTLET INVERT. NO SIGNS OF LEAKAGE. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l% 14 Shannon Way. Centerville. MA F r V pel\y Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap iiocate on site Dian): Depth below grade: N/A /feetMaterial of construction:❑ concrete ❑ metal ❑ fiberglasshylene ❑ other(explain): Dimensions: AV Scum thickness Distance from top of scum to top of outlet tee or baffle DiSta_nc_e from bottom of scrim_to of#nm of o-iitlet tep-_nr,taffJe Date of last pumping: Date Comments (on pumping?/Fecommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related o outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) ate on site plan): .� N/A veNu I below g aae: Material of construction: P ❑ concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): Capacity: gallons Design F w: gallons per day t5insp.doc-rev.7/2 612 01 8 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 14 Shannon Way.,,Centerville, MA riuNcny nuweao Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. 'Tight or Hold ina-TanK(corit:l Alarm present: ❑ Yes ❑ N Alarm level: Alarm in w Ing order: ❑ Yes ❑ No Date of last pumping: D Comments (conciftfon of alarm and float switches_ c_S: 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 AT INVERT Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 1 PIPE IN AND 1 PIPE OUT. GOOD CONDITION. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��� 14 Shannon Way,.Centerville,,MA l-- 10-eli Lr.Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1D. Pumn Chamber.(locate on site.olani: Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump ch ber, condition of pumps and appurtenances, etc.): if pumps os aialmys am not ni wori*ing Drder,system is a-condftionai pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 (6'X6') HEX PIT leaching tbarnbers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool i uTabe-r ❑ 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 rY Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way.,Centerville,_MA F.uNcI Ly nuuicaa Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 1. coif Ab'sorotion tvstem iSA'S) (cont.-) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE. LIQUID LEVEL AT 2.8'. NO STAINLINE ABOVE LIQUID LEVEL. GRADE TO SAS BOTTOM IS 10'. 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 AP KAMP .qk of rnnctri irtinn Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, ns 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 m Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Wav, Centerville, MA Property Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 13. `Nrivv flocate on site plan): Materials of construction: Dimensions Depth of solids Comments (note rnnditinn of soil sinns of hv(ira r_.faihirP IPvPI of nnndinn r_onditinn of vPnPtatinn etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon WayCenterville,MA Property Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's_Name. information is required for every Centerville MA 02632 1/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: F rovide a view off 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- }fit ' qq`• yf A-4f,40 30 o- • P t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way, Centerville, MA Property Address Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12.7 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: TOPO, BARNSTABLE GROUNDWATER MAP, FRIMPTER You must describe how you established the high ground water elevation: SITE IS> 50'A.S.L. BARNSTABLE GROUNDWATER CONTOUR MAP AT 33'A.S.L. CORRESPONDING WELL #70,71,72 AT 31-48, SDW 252 ZONE D,ADJUSTMENT FOR 8/1992= 4.3'. GRADE TO SAS BOTTOM = 10'. SEPARATION MATH 50- (33 +4.3+ 10) = 2.7' 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way, Centerville, MA riuNcny muurcaa Donald and Margaret Ditullio 14 Shannon Way Owner Owner's Name information is required for every Centerville MA 02632 1/20/2020 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 annronriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14 SkPtCh of SPwaoe IDj1pgsa1 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 l q_jot Fee l✓ `�% THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitatlon for 13isposaf bpstm Const uttion vermit Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I tt S Q,14on W4,1 Owner's Name,Address,and Tel.No. //7 Lyon R Assessor's Map/Parcel 1'70) igl Ce4ervi j/ 9I L L `! h Sv/ )� 4X Cf QGOj Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. se CAIo1, 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 C1"L i) Type of S.A.S.�P �(�� 1 V✓ ,S r Description of Soil Nature of Repairs or Alterations(Answer when applicable) ey Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code a d not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ned Date Z_ Application Approved by - — Date Application Disapproved by Dat&,- for the following reasons ""' .ca 4=� TV Permit No. Date Issued Fee !/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTHDIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plication for -Misposal 6pstem Construrtion permit Application for a Permit,to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑,Individual Components Location Address c r Lot No. /y S ,?,7& xn W,4,1 Owner's Name,Address,and Tel.No..' //9 lL yol Assessor's Map/Parcel 110 ��il W v�// (�{_ S r L- L crawl. Installer's Nam/�e,,�Address,and Te/l..'No. / / Designer's Name,Address,and Tel.No. A C Type of Building: Dwelling No.of Bedrooms_7 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 0--V- ) Type of S.A.S.. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4111 r Date last inspected.-- Agreement: J ; .y The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code d not to place the system in operation until a Certificate of Compliance has been issued by this B�Health. ----- Si ed Date � l Z /� Application Approved by Date Application Disapproved by Date'"' atC for the following reasons F k' Permit No.1 . Date Issued 'y -------*- THE COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE,MASSACHUSETTS -° Certificate of Complianre 0 r- THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k,[) Upgraded( ) Abandoned( )byd r�! // at / Q s� ,fir �� 1A Cj)I /1�2,^f'"has been constructed in accordance 1 with the provisions of Title 5 and the for 13isposal System Construction Permit N,4a0/1/" dated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the syst will fu o d i ed. Date � ko ) )4" Inspector i - ------------- ' No. /1"/ " 33 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(b, Upgrade( ) Abandon( ) System located at Ll CL,-C�_ VN A (far y 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:Construction must be mplet d wwithin three years of the date of this pe it. Date �' 7 L Approved by� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal S stem Form -Not for Voluntary Assessments _ 1 ShaMon Vay Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon .Rd 0,v"g Owner's"a"'e information is Burlington CT 0601.3 9/12/2014 required for every 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 conputer, 'Ida Martins use ony the tab 1. Inspector. key to move your ,Accu Sepcheck cursor-do not �� NOrthsidP I7t' use the return Name of Inspector key. S. Dennis, MA 02666 ,d Company Narrie A ___f Company Address fj83 •� City/Town B ✓ �� State f.Zip Code So3 v; . 1�fTA Telephone Number License Number �b s B. Certifications 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 L'� conditionally Passes ❑ Fails ❑ Needs Further Evalua ion by the Local Approving Authority Insp tor's Sgnature 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. I ttirs•3ri3 Tins 5Of8da Sewage Disposal Sylem•Page 1017 .ni► Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA iy Property Address Thomas Allan c/o .Bill Allan 119 Lyon Rd Cw ner Cw ner's Name information is required for every Burling ton CT 06013 9/12/2014 page. CityrTown State Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not hound 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: �� I 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 ❑ NO(Explain below): Jf t5irs-Y13 Title 5 official Iris px ton Form Substxtace Sewagel)lsposal System-Page 2o117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Owner's Name inforrmtionis Burlington CT 06013 9/12/2014 required for every page. City/town State Zip Code Date of Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health roval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in t distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven - tribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ ❑ ND(Explain below): ❑ obstruction is removed ❑ Y N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ ❑ N ❑ ND(Explain below): ❑ The system required pumping m e than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if( th approval of the Board of Health): ❑ broken pipe(s)are r laced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is rem ved ❑ Y ❑ N ❑ ND(Explain below): C) Further/ifailing n is Required by the Board of Health: ❑ Conditiohich require further evaluation by the Board of Health in order to determine if the t h system to protect public health, safety or the env+ronment. 1. Systass unless Board of Health determines in accordance with 310 CMR 15.303( the system is not functioning in a mannerwhich will protect public health, safety and the environment; ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t57rs•3/13 Title 5 official IrepectlonForm Subsurface SevageDisposal Sytem•Page 3of 17 A Commonwealth of Massachusetts 9M. -_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Cw ner's Name inforrmtionis Burlington CT 06013 9/12/2014 required for every page. Gtyfrown 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 ' in 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SASZaZonea public water supply. ❑ The system has a septic tank and SAS and the SASprivate water supply well. The system has a septic tank and SAS and the SAS is l50 feet or more from a private water supply well". Method used to determine distance: * This system passes if the well water analysis, perf med at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presenc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fail a 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 gj inspections: Yes No El clogged 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- El Static liquid Level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ F Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/2 day flow t,5lrs•3113 Tide 5U&iallrspectlonForm Subsurface Se,,ageDisposal System-Page 4of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Ow ner Owner's Name requir g atan is Burlington CT 06013 9/12/201.4 required for every page. Citylrown State Zip Code Date of hspection B. Certification (coin.) 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- 10,000g pd. ❑ rs� The system faiLLL 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 on to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a ace drinking water supply ❑ ❑ the system is within 20 et of a tributary to a surface drinking water supply ❑ ❑ the system is I ed in a nitrogen sensitive area(Interim Wellhead Protection Area— IW or a mapped Zone II of a public water supply well If you have answered "y to any question in Section E the system is considered a significant threat; or answered "yes" i ection D above the large system has failed. The owner or operator of any large system conside a significant threat under Section E or failed under Section D shall upgrade the system in ordance with 310 CMR 15.304. The system owner should contact the appropriate regiona fice of the Department. t.`dre•3113 TIW5Cfflclal Ins pectionForm Subsurface Savage Disposal Sytem•Page 5of 17 Commonweakh of Massachusetts -_ Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA RopertyAddress 'Thomas Allan c/o Bill Allan 119 Lyon Rd Owner Owner's Name required ion every BUrlington CT 06013 9/12/2014 page. City frown State Zip Code Date of hupection 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 prodded 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? }�j ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) l ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? I/tG f ElWere all system components, 9)whraing the SAS, located on site? l ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)prodded 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)1 D. System Information Residential Flow Conditions: #0,� Number of bedrooms (design): Number of bedrooms (actual): 330 DESIGN flow based on.310 CMR.15.203(for-example:--110 gpd x#of bedrooms): (Sire•3113 Title 5 Official Ins pcc lion Form Suosurface SevAgeOlsposW System-Page W 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1.4 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Ow ner's N information is ame Burlington CT 06013 9/12/201.4 required for every page. Oity/Town State Zip Code Date of inspection D. System Information Description: 1000 �� 1 71 ' I L gck Number of current residents: 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 Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: a 1�clyt5 Sump pump? r El Yes No Last date of occupancy: gl 204 S f,7ee 14"M 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/pe sq.ft., etc.): Grease trap pres ❑ Yes ❑ No Indus waste holding tank present? -- - ❑ Yes ❑ No on-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5irs•3113 Title 5(Official Ins pec don Form—%bsuface SevayeDisposal System•Page 7of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 .Lyon Rd OJv ner Osr ner's Name information is required for every Burlington CT 06013 9/12/2014 page. Cityfrown State Zip Code Date of inspection D. System Information (corn.) Last date of occupancy/use: Date Other(describe below): General Information P� q� m2 Pumping Records: �. oo Pe/�(J M ►3Bwcw Source of information: r— 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: 6, Septic tank, distribution box, soil absorption system Cl 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 VA system by system operator under contract ❑- Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5irs-3/13 Title 5 official Ins pec ban Form Subsurface Sevege Disposal System-Fagesofl) Commonwealth of Massachusetts _=- --- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA y Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Cw ner's Name information is required for every Burlington CT 06013 9/12/2014 page. C frown State Zip Code Date of Inspection D. System Information (corn.) Approximate age of all components, date installed (if known)and source of information: 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.): © lC N a Lectks Septic Tank(locate on site plan): 2 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 cop of certificate) ❑ Yes ❑ No Dimensions: �� X4To' 1o00 Ci S�t Sludge depth: t5ire•113 Tlw5Cfflcal Inspection Form Substrface sewage Disposai System-Pagego117 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w - 14 Shannon Way Centerville MA Property Addrem Thomas Allan c/o Bill Allan 119 Lyon Rd O,v ner ON ner's Name information is Burlington CT 06013 9/12/2014 required for every Sta page. City/rown te Zip Code Gate of hspettion D. System Information (cont.) Septic Tank(cont.) 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 LT ► � 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.): S n Ta k o vtl�r l_P•e �P2 /V e'°�S �� �P��Q CPOI Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyet e ❑ other(explain): Dimensions: Scum thickness Distance from top of-sc o top of outlet tee or baffle Distance from om of scum to bottom of outlet tee or baffle Date ast pumping: gate t5ns,y73 Tide 5011dallnspactlonForm Subsurface SewageDlsposal System-Page 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Cw ner's Name nforr require fo isr every Burlin ton CT 06013 9/12/2014 required fo page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 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 ins p ion)(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 I st pumping: Date Co ents (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ire•Y13 Tide 5aftclattrspacllonForm SubsWaceSevageDisposal Sy.*am•Page 11 of 17 Commonwealth of Massachusetts - -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - - 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 11.9 Lyon Rd Cw ner Cw ner's Narre requiredfo is Burlington CT 06013 9/12/2014 required for every 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 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.): of Ol r�-P�'G�f 7y 9-4�_ o%c J Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No` Comments (note Condit' of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditio pass. Soil Absorption System (SAS)(locate on site plan, exc tion not required): If SAS not located, explain why: t5irs-N13 Title 5 Official Ire pec ban F orm Subsuface SewveDisposal Swbarn-Page 12of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Shannon Way Centerville MA Property Addrew Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Cw ner's Narre equiredfonrevery Burlington CT 0601.3 9/12/2014 page. Citylrown State Zip Code Date of hspection D. System Information (cons.) Type: leaching pits number. / ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): .s /Y12 iS CI-Pa.. a 4dv-e3�� �1 v t?G Cesspools(cesspool must be pumped as part of inspection)(locate on sit Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension cesspool M rials of construction Indication of groundwater inflow ❑ Yes ❑ No t5irn•3113 Title 5Ctfklal Ire pectionForm Subsuface Se%ogeDlsposal Syslem•Forge 13d 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 :Lyon Rd Cw ner Cw ner's Name iretion Is required for every Burlington CT 06013 9/12/2014 page. City/Town State Zip Code Date of hspection D. System Information (coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition egetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condi ' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 5re•3113 Tide 501ficlalIrr pec bon Fnlrc Sutsuface Sevege Disposal Sy3em-Page 14tl 17 Commonwealth of Massachusetts __ - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 14 Shannon Way Centerville IMA Property Addrew Thomas Allan c/o Bill Allan 119 Lyon Rd Owner Cwner's Name information is Burlington required for every ,ton CT 06013 9/12/201.4 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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. L'7 hand-sketch in the area below ❑ drawing attached separately 1 A'l qz 1 • Y r�� r 0'I p /`i t5irs•3113 Title5rYflcief Iris pectlonForm SubsvlaceSWAG960ispnsal SAtem•Page 15d 17 Commonwealth of Massachusetts - -__ -- Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -_ 14 Shannon Way Centerville MA Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd O,v ner Cw ner's Name inforr tion required for every Burlington CT 06013 9/12/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) S—itee Exam: ED/Check Slope ad Surface water V Check cellar (Shallow wells Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑,/ Checked with local excavators, installers -(attach documentation) L7 Accessed USGS database-explain: -rya� 4 41.e S wC4401 Ind, —&f MV7r4 You must describe how you established the high ground water elevation: 2 • Q a-A s /74 4 3. Cor#4,.Spw%G,t Uj'ed #-?o, 7/, 7L D -3i-ye Wzrz y• G 12 d fi Sltr AS 0 ff-Orn io. v S: Q9In arm-�d►� `?il a Sv — 3 3 i}- q• 3 H 0 = 2. 7 Before filing this Inspection Report, please see Report Completeness Checklist on next page. Eire-Y13 Tine 5Gflclal Ins pec ton Form Suhsufam Sev,09e0ISP069 System-Page 16of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form _ — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 1.4 Shannon Way Centerville MA h Property Address Thomas Allan c/o Bill Allan 119 Lyon Rd Cw ner Cw ner's Name information equiredo re Burlington CT 06013 9/12/2014 required for every page. Citylrown State Zip Code Date of hspection E. Report Completeness Checklist l!1 Inspection Summary: A, B, C, D, or E checked EV'Iinspection Summary D (System Failure Criteria Applicable to All Systems)completed ICY System Information—Estimated depth to high groundwater O Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Tine SCfflclal Ins pec don Form Su45urtace SevegeDisposy SAW m•Page 17 of 17 L 0 t,-VT W A E P E R F41 T N 0 Ike&9Z VILLAGE 1 N' 5 T A L L E R'S NAME A A D 0 9 E S S 0- L//,C- (710 --- AUX., 2 U I L D E rl 0 Ft OW,H E41 <b —M , T I S S U E D 7 DATE COMPLI A NCE . I SSUED A ��-�< �' ��/' ��. �� �! / ,� o a �„ __ __ - __ _