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Home My WebLink About0076 SHEAFFER ROAD - Health r 76 Sheaffer Road Centerville. P A =.. 172. 031 No. 42101/3 ®RA Ps H(4,%v ag 10/0u a ® ® C I I { r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 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: A. General Information 1�7 O 3 When filling out Z — forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name f� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 l❑ Conditionally Passes ❑ Fans c I -5 ❑ Needs Further Evaluation by the Local Approving Authorityell f 10/01/2008 Inspector's Sighaturbs Date GPI t The system inspector shall submit a copy of this inspection report to the Appro ing AuRorityr�"1 (Board of Health or DEP)within 30 days-of completing this inspection. If the system is 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•09/08 f°G' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 2 • r fi. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y, ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken.or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Sheaffer Road M Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a.private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails..I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department.. (Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done..You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of,the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 2 ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distribution box and two leaching trenches 38'x2'x2' Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No . Water meter readings, if available (last 2 years usage (gpd)): 2006:69,000 2007:43,000 Detail: 2006:189 gpd 2007:117 gpd Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitarywaste discharged to the Title 5 system?9 Y ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wMK., 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: New leaching installed in 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leaka e.System vented through the house vents. Septic Tank (locate on site plan): Depth below.grade: 6"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. Sludge depth: 311 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town 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 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Pump septic tank every two years.lnlet and outlet tees are in place.No.evidence of Ieakage.Tank appears to be structurally sound. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Sheaffer Road M Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 76 Sheaffer Road Property Address ., Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9c� 76 Sheaffer Road M Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching`pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-38'x2'x2' ❑ 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.): Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching trenches were dry at time of inspection. 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 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 I Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ■ zoom Out J J J J J JIn � f vv if f r �f rrM1�'� fi ri j r l ri r r 1} fi �f r ri rtr fff -:tip Jr - r , f - 0 ; 20 Feett ,= ti N I Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER inhf 90nF-9n0A Tn... of NAA All rinhro roccr,,, http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=l72031&map... 10/2/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Bottom of leaching 40' 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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data. USED:Technical Bulletin 92=000=01 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 76 Sheaffer Road Property Address Joseph M. Ferraro Owner Owner's Name information is required for Centerville Ma. 02632 10/01/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS . ExEcuTr%E OFFICE OFSENVIRONMENTAL AFFAIRS s �. CEO DEPARTMENT OF`ENVIRONMENTAL I Ilk I :TI'ON DEC 26 2002 T�WN.,OF BARNSTABLE TITLE 5 ......... .......... OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 76 'Sheaffer Rd -� -.Centerville Owner's Name: . .Maribeth Desley Owner's Address: TL-- k. Date of Inspection: �' �--/jl°—[S MAP Name of Inspector:(please print) Wi 1 1 i am R_ . Robinson Sr. PARCEL. Company Name: ,William E. Robinson Septic Service LOT Mailing Address: P 0" Box 1089 _Centerville. MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported. below is true,accurate and.complete as of the-time of 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: Masses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 'Ins ectors Signature:P � �i 1'(��l�`�.�+�,.�....� Date: Q The system inspector shall submit a copy of this inspection report to,the Approving Authority(Board of Heattt or DEP)within 30 days of completing this inspection.If the system is a shared system or bas a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l l NOT FOR VOLUNTARY`ASSESSMENTS OFFICIAL INSPECTION FORM ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO f PART A CERTIFICATION (continued) Property Address.. 76 Sheaffer R� Centerville Owner. Maribeth npsley Date of Inspection: Inspection Summary::Check A,B,C,D or E/ALWAYS complete`ill of Section D A. Sys m Passes: four d an information which indicates that any of the failure criteria described in 310 CMR I have not Y 15.303 or in 3 10 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Syste mConditionally Passes: One or more system coon.heed to beTeplac or mponents as described in the"Conditional P lived e'sec b tithe Board of Health,will pass. ` repaired.The system,upon completion of the replacement or repair,as approved Y N ND in the for the following statements.if"not determined"please Answer yes,no or not determined(Y, ) 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. ND explain: 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 obstruction is removed = s% distribution box is leveled or replaced NU explain: The system required pumping more than 4 times a Year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed t ND explain: f ' `Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION(continued) Property Address: 7 A 9beaf f er Bd �entervill� Owner: sley Date of Inspection: ` -73 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 faring to protect public health,safety or the environment. 1.\ystem ystem will pass unless Board of Health determines h accordance with310 CMR.15.303(1)(b).that the- is not functioning in a manner which will protect public health,safety.and the environment:.. _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh: 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment.- The system has a septic'tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank'and SAS and the SAS is within a Zone 1 of a public water supply. P PP .y^ 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 160 feet but D feet or more froth a private water supply well'•.Method used to determine distance . 1 i '*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fa' ure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY I ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.-INSPECTION FORM —PART A ,. , CERTIFICATION(continued) Property Address: Owner: Date of Inspection: �2— =` D. System Failure Criteria applicable to all systems:. you must indicate"yes"or"no"to each of the following for all inspections: S' ol Yes No or stem component due to overloaded or clogged SA or cesspo Backup of sewage into facility y 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 SA or cesspool ' _ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ M Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s):Number of times pumped ground water elevation. Any portion of the.SAS,cesspool or privy is below high 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 l of a public well. Any,portion of a cesspool or privy is within SO 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the prcsenc ora m,provided t at no other failure criteria nitrogen and nitrate nitrogen is equal to or less than 5 / alysis must be attached to this form.] are triggered.A copy of the an ll (Yes/No)The system fails.I have determined the system st m fails.re of the The system ove failure criteria exist as owner should contact the Board of described in 310 CMR 15.303,the Y Health to determine what will be necessarylo correct the failure. �E. Large Systems: d to 15,000 To be considered a large system the system must serve.a facility with a design flow o[10,000 gp �pd' " o"to each of the following: indicate either es or n You must m `Y (ffhe following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Y Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is COD idered 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 should contact the appropriate regional office of the Department. q.304.The system owner 4 f Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 Sheaf f er Rd Centerville Owner: Mari teeth Desley Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No C/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?: !/Nave large volumes of water been introduced to the system recently or as part of this inspection 7 Were as built plans of the system obtained and examined?(If they were not-available note as N/A) . v Was the facility or dwelling inspected for signs of.sewage backup? v— 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: Yes no t�xisting 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 Sheaffer Rd , Centerville Owner: Mari.heth DPR av Date of Inspection: 14-,�L-— '—d 2, FLOW CONDITIONS RESIDENTIAL r. Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):A-6 [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):/V Water meter readings,if avail ble last 2 years usage d 2 0 0 0 '9,7 0 0 gals Sump pump(yes or no): Last date of occupancy: --I -n 2.0 01. 3 8,0 0 0 gal s CO MERCIAL/I1�IDUSTRIAL Type o establishment: Design ow(based on 310 CMR 15.203): Qpd Basis of esign flow(seats/persons/sgft,etc.): Grease tr p present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER`oescribe) °( GENERAL INFORMATION Pumping Records Source of information: ,ZOO Was system pumped as pari of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE O/F SYSTEM e�Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): d 6 I Page 7 of 1 I OFFICIAL INSPECTION FORM NOT'FOR_VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL- SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Sheaf f er Rd en ervi e Owner: Mari et Des ey Date of Inspection: )'gL BUILDING SEWER(locate on site plan) Depth below grade: Mated s of construction: cast iron _40 PVC other(explain): Distant from private water supply well or suction line: Comore is( n condition of joints,venting,evidence of leakage,etc.): SEPTIC.TANK: _ locate on site plan) Depth below grade Material of construc tion:=concrete_metal_fiberglass_polyethylene —other(explain)- If tank is metal list age: Is age confirmed—by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: ; Sludge depth: Distance tom top of sludge to bottom of outlet tee or baffler Scum thickness: , a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: _?'' r 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. : / l GREA E TRAP:_(locate on site plan) Depth b low grade:— Materiallof construction:_concrete_metal_fiberglass_polyethylene_other (explain) Dimension s: Scum thi kness: 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: Conuncdts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION N FORM-NOT FOR VE NSPECTIO NTAF F ORM TS SUBSURFACE SEWAGE DISPPOSA CYS - SYSTEM=INFORMATION(continued} Property Address: Rd Owner: Desley Date of'Inspection: / -711" or HOLDING TANK-. (tank must be pumped at time of inspection)(locate on site plan) TIGHT , grade' — - fiberglass e othec(e Depth below xpla►n):; concrete metal g —� olyethylen Material of construction: _ Dimensions: allons Capacity: allons/day Design Flow: Alarm present(yes or no):_� Alarm level: _ Al in working order(yes or no): Date of last pumping:_1__ float switches,etc.): Comments(condition of larm and DISTRIBUTION BOX: (if present must be opened)(locate on site plan) f.� evidence" of. . an Depth of liquid level above outlet invert evidence of solids carryover, y „ , Comments(note if box is level and distribution to outlets equal,any leakage into or out of box,etc.): PUMP CHAMBER (locate on site plan) Pumps in working o der(yes or no): Alarms in working rder(yes or no): Comments(note c ndition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURF-ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C.._ I SYSTEM INFORMATION(continued) Property Address: 76 Sheaf f er Rd Centerville Owner: Maribeth Desley Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ''I/(locate on site plan,excavation-not required), If SAS not located explain why Type leaching pits,number:_ 171iing chambers,number: eaching galleries,number: leaching trenches,number,length:,X-- 3, � -�et. �e►��S 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.): o6 �� CES5TOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth- op of liquid to inlet invert: Depth oflolids layer: . Depth of scum layer: Dimensionskof cesspool: Materials of\construction: Indication o lgroundwater inflow(yes or no): 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.): !A 9 t , Page 10 of 1 l FORNOTFOR V MNTSOFFICA NSECTION E SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C.: SYSTEM INFORMATION`(continued) Property Address: 76 Sheaf f er Rd en ervi e Owner: Marib—eT=esley Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. ' -ram` • :.'.. 1 .: • r s 1 _ J ci ? 7 10 Page l 1 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 Sheaf f er Rd Centerville - Owner: Maribeth Desley Date of Inspection: f 2 —M —6, SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: —Observed site(abutting property/observation hole within 150 feet of SA Checked with local Board of Health-explain: ,o �..s /`� P� Checked with local excavators,installers-(attacli documentation) Accessed USGS database-explain: You must dess�be ho you esta fished the high ground water elevation: W i 11 CO11�10\'WEALTH OF MASSACHUSETTS ExECL THE OFFICE OF ENNIRON INIEN TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION =- r ri ONE N Z TER STREET. BOSTON K-%0210c 16l,i 292-550k, TRi.DY COX. Secre:ar ARGEO PAUL CELLLCCI DAVID B STR'-'HS Governor Cotn.mimoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prop"Address76 Sheaffer Rd.. , CentervilkaneofOwrw Hermanson Date of Inspection: 3` 0 0 Address of Owner: Name of Inspector:(Please Print)Wm. E . Robinson Sr. 1 am a DEP approved systeM inspector pursuant to Section 15.340 of de 5(310 CMR 15.000) cort,partyNan,e: Wm. E . Robinson Ti eptic Service Mai-lingaddress: PO BOX 1089, Centerville MA Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: L/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails s / /�� Inspector's Signawre: �o[� Y 1�►'L ✓ "" Date The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS a � <000 revised 9/2/98 pagriorll n ii �f?ed on Recvdrd Panu SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'rop"Address76 Sheaffen Rd.. , Cehterville Owner: Hermanson Date of inspection: 3 INSPECTION SUMMARY: Check 00, C, o/ D: A. SYS PASSES: I have not found any information which indicates that•any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system. upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate es, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined',explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The.system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed revise^ 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icon6nued) Property Address: 76 Sheaffer Rd.. , Centerville Owner: Hermanson ° Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the pub is health, safety and the environment. 1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS T FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER revise, PtQc3of11 SUBSURFACE SEWAQE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Address: 76 Sheaffer Rd.. , Centerville Owner: Hermanson Date of Inspection: D. SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface,water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LA GE SYSTEM FAILS: You mus indicate either "Yes' or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public ealth and safety and the environment because one or more of the following conditions exist: Yes o the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The ow r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. revised 9/2/98 Pagt4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 76 Sheaffer Rd.. , Centerville Owner: Hermanson Date of Inspection: G-3-� Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes,/ No _ Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at 6.0.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11,5.302(3)(b)] V- _ The facility owner (and occupants,if different from owner) were provided with information on the proper s aintenanci-0f SubSurface Disposal Systems. se seri 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'rop"Address: 76 Sheaffer Rd.. , Centerville Owner: Hermanson ° Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom. Number of bedrooms(design): 0 Number of bedrooms (actual): Total DESIGN flow 3 -3-0 Number of current residents: Garbage grinder lyes or no):_/k,U Laundry(separate system) (yes or no)%L d; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):do& U Water meter readings, if available (last two year's usage(gpd): 1999 165, 000 gal. Sump Pump(yes or no):ti O 1998:i 117, 000 gal. Last date of occupancy:G-3-cam✓ COMMERCIAL/INDUSTRIAL: Type f establishment: Desig flow: gpd ( Based on 15.203) Basis o design flow Grease trap present: (yes or no)_ Industr al Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate of occupancy: OTH R:(Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) �•d If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: �i �2•� Sewage odors detected when arriving at the site: (yes or no) ?J revised 91/2/9E Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinred) 'ropertyAddress: 76 Sheaffer Rd.. , Centerville Owner: Hermanson Date of Inspection: C BUILD G SEWER: (Locate n site plan) Depth be[ w grade:_ Material o construction:_cast iron_40 PVC_other(explain) Distance rom private water supply well or suction line Diamet Commen : (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:: � Material of construction:14oncrete_metal_Fiberglass _Polyethylene_other(explain) It tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: & -f 4- G Sludge depth:' , Distance from top of sludge to bottom of outlet tee or baffle: L/G Scum thickness: /-3 , Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: O PC— %1-, :omments: (recommendation for pumping, condition of inlet anj outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage.etc.) /V V—t� �' Ti+ �- I �+ ! /��L�3 >� L'7//>' G t' GREA TRAP: (locate n site plan) Depth be w grade:_ Material f construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensio s: -- Scum thi kness: Distance from top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comm nts: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage, etc.) L�e-vised Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION(continued) brop"Address: 76 Sheaffer Rd.. , Centerville Owner: Hermanson Date of Inspection: a 3 TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material of construction:_concrete metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Dot of previous pumping: Com ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) TT�� Depth of liquid level above outlet invert: V Comments: (note if level and distribution is equal, evidence �olids carryover, evidence of leakage into or out of box, etc.) - PUMP C MBER:_ (locate on site plan) Pumps in orking order: (Yes or No) Alarms in orking order(Yes or No) Comment Inote co dition of pump chamber, condition of pumps and appurtenances,etc.) revise. 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 76 Sheaffer Rd . , Centerville Owner: Hermanson Date of Inspection: c_e / SOIL ABSORPTION SYSTEM(SAS):V (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_Z leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) /eA. g l' i�Ci' 7- C POOLS:_ Y, hoca on site plan) - Numbe and configuration: Depth-t of liquid to inlet invert: Depth of solids layer: )epth of cum layer: Dimensio s of cesspool: Materials f construction: ` Indication f groundwater: y i flow (cesspool must be pumped as part of inspection) Comments' .. Inote cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (Iota on site plan) Materia of construction: Dimensions: Depth o solids: Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise: 9/2 '7C • � Pegc 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -ropertyAddress: 76 Sheaffer Rd., Centerville iwner: Hermanson .)ate of Inspection: C SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) l s I � L 3t� '27 l , revised 9,12/96 Page 10of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) rop"Add►ess: 76 Sheaffer Rd.. , Centerville Owner: Hermanson Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater f O Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions `� Checked with local Board of health Checked FEMA Maps _Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 3 f-4; I /�o l 5 o Ro .,W 19 y revise.A 9/2/95 Page 11 of 11 TOWN OF BARNSTABLE LOCATION SEWAGE # 97 5 VILLAGE ^ ASSESSOR'S MAP &LOT /�7�3l INSTALLER'S NAME&PHONE NO. ,P Mom- -3C SEPTIC TANK CAPAcrff ` LEACHING FACILITY: (type) /,,�i1L t (size) NO.OF BEDROOMS BUILDER OR OWNER 30{� PERMITDATE: COMPLIANCE DATE: - la--I, 92 Separation Distance Between the: 71- Maximum Adjusted Groundwater Table and 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 Lrcl�g hing Facility(If any wetlands exist within 300 feet of le f i &!u--Q Feet Furnished by �f-* 2�e-t� ,3L. ��Z No. 17 v " Fee r 7 --0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprfcation for Migogal *p5tem Construction Permit � Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Adze or Lot �� Owner's Name,Address Tel. o. Assessor's Map/Parcel 'A m 1/� /� Ins Name,Address,and Tel.No. Designer's Name,Address and Tel.No. m 1 e Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �3 3 D gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature Repairs or Alter�* Answ when applicable) �— 2 u t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio s of 'tle 5 of the En 'ronm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by ' Boarde �. Signed O Date Application Approved byjwm2lDate Application Disapproved for the following reasons Permit No. Date Issued -03 x r N..--Iq'Tia (/ Fee u[er: com in THE COMMONWEALTH OF MASSACHUSETTS Entered P Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lotion Add or Lot Owner's Name,Address and Tel. o. Assessor's M /Parce� (� �� V v�3 Installer' Name,Address,end Tel.No. Designer's Name,Address and Tel.No. Type of Building: 2 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 D gallons.per day. Calculated daily flow gallons. Plan Date Number of sheets- Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature Repairs orAltera ins(Ans�en applicable) _7 2 u r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisio s of 'tle 5 of the;Me ' onm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by t ' Boazda �Signed VA C 412Date Application Approved by _ Date Application Disapproved for the following reasons `�v Permit No. . r y Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY that the O�Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( )by a/ at 4- C.GvJt- '� has been constructed in accordance with the provision of Title 9 and the for Disposal System Construction Permit'�o dated Installer Designer ='4-- `e The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date -n—b -67) Inspector V o. —— �------------------------ _ = N Fee ��...�.- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 30i0po5al *pgtem Congtruction Permit Permission is hereby ranted to Construct )Repair( Upgrade( ,r- don System located at S ' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes hi /her duty to comply with Title 5 and the following local provisions or special conditions. f Provided:Constructi to must be om leted within three years of the date oft '�pe it. J4 /� �y n� Date: !l/ � Approved by f � L 8 � ' �,, tZI , 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) n hereby certify that the application for disposal works construction permit signed by me dated a , concerning the property located at ;7G v eets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility ''• There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) L� B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: /o, ,e LICENSED SE C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert ,. r� � _ � •+ `�-t� /�� C� �a� � 0 _t ., � i _, _ .._-- - � � . .. TOWN / OF BARNSTABLE c� LOCATION 7C Sh.aQ„. &; � SEWAGE# __/ 7 VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /a B� LEACHING FACILITY: (type) (size)�— 3 �k� ', NO.OF BEDROOMS BUILDER OR OWNER C�ct{ ,ti PERmrrDATE: /0"/f- 7 COMPLIANCE DATE: 1 , 9 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 't 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 Lea hing Facility(If any wetlands exist within 300 feet of le chi g f i /f/B�Q, Feet Furnished by `