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0541 SHOOTFLYING HILL RD - Health (2)
t 541 Shootflying f i j i road Cente'rville A= 193-626 UPC 17634 NQ.2�, 153�COR MA8TIN08.UN \1 �y V/ i No. 2 DO g r 2 88 Fee A00 -- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4__� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes APPlitatiOn fOr Digpo5al *pgtem COn5tructi0n permit Application for a Permit to Construct( ) Repair(y� Upgrade( ) Abandon( ) U Complete System ❑Individual Components Location Address or Lot No. /J f �j �tl�/���q�ij�! Owner's Name,Address,and Tel.No. Igo s�� Assessor's Map/Parcel Install ,Add e$s,an gel.No. Designer's Name,Address and Tel.No. _ Type of Building: Dwelling No.of Bedrooms Z Lot Size ® sq. ft. Garbage Grinder (,,Zp Other Type of Building &WC( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re jquired) 3 NO gpd Design flow provided 3�� gpd < Plan Date Z/ Number of sheets Revision Date Title p h ? Size of Septic Tank / ®� Type of S. .S. Z,.'W5- - Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo d of alth. Signed Date Application Approved by ,s'. Date Application Disapproved by: Date for the following reasons Permit No. ,�"(�G/ — 2 05 Date Issued S d Cf No. Fee ADO THE COMMONWEALTH OF MASSACHUSETTS ------.. f- Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPrication for Migonf *potent Construction Vermit Application for a.Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No.�` 1 i � �� Owner's Name,Address,and Tel.No. Assessor's o,z6 / 4f0lye Installer's Name,Addre s,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( � Other Type of Building 10! eWe._e No.of Persons Showers( ) Cafeteria( ) Other Fixtures /� Design Flow(min.required) �G/ gpd Design flow provided �j � gpd Plan Date g l Z/ Q� Number of sheets Revision Date Title Z2' D24 11/V/0'9' N Size of Septic Tank Jf (�� Type of S.X.S. Lf� J�D r Description of Soil Nature of Repairs or Alterations(Answer when applicable) •�-- cam•y�. Date last inspected: " `j 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 arid not to place the system in operation until a Certificate of ' Compliance has been issued by this Board of Health. d Date 1. ✓ ._. - l , Sig q !,7 I'r Application Approved by Date g Application Disapproved by: Date for the following reasons ;3 Permit No. DU,9 2 8 Date Issued g if THE COMMONWEALTH OF MASSACHUSETTS " BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (Upgraded ( ) Abandoned( )by / has been constructed in accordance at Z/1Z with the provisions of Title 5 and the for Di posal System Construction Permit No.ZaQ'j"2 56 dated Installer Fla a-To (_o"T Y 1 N_ST Designer DOW (ZNIP1~, #bedrooms 2- Approved design flo 0 (LUV►o t D gpd The issuance of this permit s all not be construed as a guarantee that the system 4,1I fu.c .n as desig ed. Date ��,,yy "1 '� 1 t) Inspector i, •�: �. No. 2znoq-- _._., ._._..,_.___ _..._._,-,-_. .__._.-.-._._.-.. -•-.---_,_ .__�.,_._ -.. . ..- Fee- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Migogal 44paem Construction Permit Permission is hereby granted to Construct ( ) e air ( /) Upgrade ( Abandon ( ) System located at � ��`fQpj� �V/m9 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this perm4 Date of Gf Approved by ,S. , I , for-`�/ e�•t-► ,�y. Town of Barnstable P# THE Departinent of Regulatory Services IRLA>trrErrA»� Public Health D1visim Date dd� 0 MASI a 200 Main Street,Hyannis MA 02601 Date,Scheduled Time— jDAKA tA— Fee Pd. Soil Suitability Assessment for Sewage lsposal Perfonned By: Witnessed By: LOCATION,& GENERAL INFORMATION Location Address spry��Q � Owner's Name He- ^-I M r /ems. Address Ceh�e.,r1.r Assessor's Map/Parcel: /9� �A Engineer's Name �Q f/ NEW CONSTRUCTION REPAIR Telephone It �0, D Land Use i�J Je A41'� Slopes(%) Surface Stones_A�P a ig Distances from: Open Water Body A2} R Possible Wet Area /a 0 ft Drinking Water Well UAft Drainage Way ft Property Line eft Other ft SKETCH,(Street name,dimensions of lot,exact locations of lest holes&perc tests,locate wetlands im proxinuty to holes) W Z ��� t ► Ir Parent material(geologic) CVtw F'�t�d�! t v r' _ Depth to Bedrock —� Depth to Groundwater: Standing Water in flolle:, �— Weeping froln Pit cc &0 A_P�_-_ Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soil MOW. Depth to weeping from side of obs.hole: _— In. dfuutldwuter AdJuslment Index Well If Reading Date: Index Well level _ Ad�l,faetor m _` Adj.flrtwndwater Level PERCOLATION TEST ` I�at�� . c Time 11 0(p Observation ✓(�i l� Hole# Tinto at 4" e Depth of Perc Time at 6" Start Pre-soak Time @ I ram" Time(9"-G") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed ✓ Site-Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Bac! ***If percolation test is to be conducted within 100' of wetland,you roust first notify the. Barnstable Conservation T)ivision at least one (1) week prior to beginUing. Q:\SEPTIC\PEItCFORM.DOC DRER'.OBSERVATTON FroL]C LOG Depth from Soil Horizon gale # Sail Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones;Boulders, 69` Co istency.% ravel hie, 5 DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Hole# Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottlin g (Structure,Stones,Boulders. �. Consis ency.%Gravel za ° 4-00SC: DEEP OBSERVATION BOLL LOG Depth from Soil Horizon Hole# Surface(in.) Soil Texture Soil Color (USDA) MotSoitling Other (Munsell) ottling (Structure,Stones,Boulders. Co siste c G vel — --- ]SEEP OBSERVATION HOLE LOG _ Depth from Soil Horizon Hole# il Tcxh�re So Surface(in.) Soil Color Soil Other r (USDA) (Munsell Mottling (Structure,Stones;Boulders, Consistency.c I Il+lood Insurance Rate MAR: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes _ D6pth of Nyturally Occurring Peryious ldlaterial Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Oertification I certify that on q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in�10 MR 15.017. Signature Date 40 Q:1$EFTICU'ERCF0RM.D0C OCT-05-2009 13:52 From:BORTOLOTTI CONST 5084289399 To:508 790 6304 P.1/1 FROM :down cape engireering inc FAX NO. :15083629860 Oct. 05 2009 12:18PM P1 Town of Barnstable Regulatory Service.9 t g Tbaw as F. Geiler,Director Public Health Divisiono6y " 7'liomse McKean.Director 200 Maid Straw,flyanpis,MA 02601 ()Mi;i;- 508-862-4644 rnx: 508-790-6304 rngtnller&Jkshpicr C.'cr. icafigli Forw Date: �0 /01 Sewage PeranitO 0 O" a� Assessor'a Mlnp\Pnreel Designer: �Owv,, Cafd, ��I.�le h hiaj'al.lcr: Address: u M � Addrnaz: �o 60�c ?L CIA 9 Se)l 10I11iw6�s�wy issued a permit to ;nsta.«n (clale) r �j (11Yy1aL1141'� HH1)6C y stem aft y �►!�U f ( / �8.9C(I OIl 11 l�Cdl llrEtwn b y / a / Ism y x -- �_ dated esl�1 Q 1 c-crtftt than The scpd.c system referenced ilhuvo wus inatulled hubstaintial,ly according to the design.. Nvblch may include minor. approved cbnn.ges such aslatcail n;loeatiou of the diguihutiou box anti/or septic tank r cerl.i.f,'y '11:Iut the septic systern referenced ribove vms 'irletallled with maljor changes (i.c. grenter tllrin 10' lateral relocation of the SAS or rn'ly vcrlival 1-CIOCal'1i011.Of!any COMPol)Cn'I: ul'ffie t3vpUc systwu)but in accordance: with State Alt Loea.l.Rcgulati,ons, Ylau revision or uellifled us-buil.l„by dwiigner w,Ballow, fJANIFIIqA (ltlsl rr's Sagnc�tlicr. OJAEA CIVIL (A --�. NO-4 50 (13eslgner,'s Si Intl-ITix Do r ® Slatllp Hore.) Its KANIJ lel'K,IUN XQ 2eA]i1Vc"fAIHL1i, t u �i�g.7n nYyrg�ln cr.RT7T?T��TP cam &:gmiyum if Wa.0 No.r 'gun 'ISSl1KD lyy,-nL MOTH T.ftl:S QR?A a)-) A.t+-N111]�1:' c:..aalut ADi� TWN 11ARNSTAl1LK P11111j1:N,F,Ajjff , $iON. TAANK Y(1t.. 0.l'rori111Vge1)tlGr1arIAaer(''cjllflcatlon hnn 3-26-04.doe I TOWN OF BARNSTABLE I p LOCATION SS// SEWAGE#,,9611' 0 VILLAGE fg.,��,.w,//� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ��as'y5/ae ���t' c/�iu✓ 5��`�J,C SEPTIC TANK CAPACITY lzd e e .Z/e LEACHING FACILITY:(type) (size) Ye. NO.OF BEDROOMS OWNER 4A L PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). /dQ feet FURNISHED BY 00 „0)��� - n 9,�� mh � `e � �e '� � �� i „�, i � _ _. 3 f I ( �l'�i+ i �h� s Commonwealth of Massachusetts '�0 Title 5 Official Inspection Form �-i' r-'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � ?...... 541 Shootflying Hill Rd Property Address EMI Joyce Munsey Owner Owner's Name information is r, required for every Centerville MA 02632 10-3-1$;;. page. City/Town State Zip Code Date of I'nYspection EMa.I' 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. A. Inspector Information cS!# (gybS^ Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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) have determined that the system: ;1 + ®. Passes.. . 2. .❑ Conditionally Passes 3.. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-3-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts } a Title 5 Official Inspection Form -lY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2)' System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 . Commonwealth of Massachusetts 3 Title 5 Official Inspection Form (� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootfl in Hill Rd J,•T,,y. Y� 9 Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): j ❑ 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): 1 I ❑ 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 El ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form �� wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ` ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ' ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This „. system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. t, For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5 insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts N. Title 5 Official Inspection Form ICY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd �t Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection, Forme i-t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd J - Property Address Joyce Munsey - Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: f Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2018Date t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 �.� Commonwealth of Massachusetts r� y Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootfl in Hill Rd Jr.•T., ; Y 9 J Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form r t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •: :„ ' Zr.� , 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract t ❑- Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2009 Were sewage odors detected when arriving at the site?. ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18"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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form r. i,�Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: .. feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts a y Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd J. Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville . MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form hf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ; ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits s number: ® leaching chambers number: 4-Infiltrators ❑ leaching galleries number: , ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form ! 1.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY F•; >' 541 8hootflying HIII Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrator field in good working order and empty at inspection with no sign of failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I i i t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts y� Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments *> X g p Y rY 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ., iC —41 t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 F Commonwealth of Massachusetts Title 5 Official Inspection Form ,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells , Estimated depth to high ground water: 12' 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 Ireviewed: Date t ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, 'installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ��. Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 541 Shootflying Hill Rd �r Property Address Joyce Munsey Owner Owner's Name information is required for every Centerville MA 02632 10-3-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts 1 ' P 03 J64z� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for uu!untary Assessments Property Address _ Owner Cw ner's Name � / infornnation is required for every _ page. City/Town State Zip Code Date of Inipection 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. fmportaor "fnn$ A. General Information filing out forms on the computer, use only the tab 1. Inspector. key to move our ' cursor-do not use the return Nlame of Inspects key. company Name Company Address G+✓7 City/Town r 50 ` / / �0 state � T Q Y�— Zip Code Telephone r 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 16.340 of Title 5 (310 CMR 18.000). The system: f a'Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority g Inspec is signature taste 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 god 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. tSns•3113 Title 5 Official inspection F orm Subsufam SewageDispood System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disptisal System Form - Not for Voluntary Assessments Property Address 2 ✓`7 v"l Ow ner Ory ner's Name requir atbn is CC>vt requlredfor every -_ page. Cftyrrown State Zip Code Date of rnspeotjon B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System P sse s: I have no t found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, vvill pass. Check the box for"yes', "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please ex0ain. 1 The septic tank is metal and over 20 years old"-or the septic tank (whether metal or not) is structurally unsound, exhibits sub antial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existinil tank is replaced with a complying septic tank as approved by the Board of Healt h. A metal septic tank wiU. 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): t5ns 3n3 Title5officialIrispecdonFormSubsuYaceS0wag0D1sp06alSystem-Page2of17 Commonwealth of Massachusetts v Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1�e V11 Y')I /C-) C� C'/— Ow ner Owner's Nameinformation is /� requrcedforevery page. Qtyrrown State Zip Code Gate of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ 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(Wth approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box Is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(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 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 t5ns•3M3 Title 5Offidd irspectcnFornt Subsirface Sewage DispoW S)ftm•Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner Owner's Name A VI-1 04 1 reorn-ation is wired for everyLeo k✓t/ /r `/ - �i� 0,)- 6 page. cityrrown State Zip Code Date o spectlon B. Certification (coat.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*'. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You,rmut indicate "Yes" or"No" to each of the following for 9 Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6° below invert or available volume is less than day flow t9ns•Y13 Tile 5 Oft cial Inspec ton Form Sutuurface Sewage Disposal System-Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments sw Property Address Information is e h ��� lerequired for every --- page. Ctyy/'rown State Zip Code Date of I spec ion B. Certification (cant.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or zz 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 r� tributary to a surface water supply. ❑ Ly 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 coilform 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.] ❑ �✓'y� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 Og pd. ❑ ❑/ The system fails I have determined that one or more of the above failure criteria exist as described,in 310 CM 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. TWe 5 0MC181 Inspeckn F orm SuWWace Sewage 01sposo System•Page 5of17 Commonwealth of Massachusetts Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Ae—, P, 1✓'1rI� ON ner Car ner's Name / information isCe H�✓ ,-/ Ile e �� �aZ G required for every page. City/Town State Zip Code Dat 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 C'� ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ L5 Were any of the system components pumped out in the previous two weeks? ❑ [Er 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? Qr ❑ Was the site inspected for signs of break out? r' Q ❑ Were all system components, excluding the SAS, located on site? is Q` ❑ 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: ;CI Existing information. For example, a plan at the Board of Health. [�'J ❑ 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: Number of bedrooms (design): Number of bedrooms (actual): --- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x #of bedrooms): t&rm'3M3 7iue5Official Ins pec bon Form Subsurface Sewage Disposal S wag sp y56sm-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cw ner OYv ner's Name (-� I ✓ information is /'eV,_} ✓r /4 �o� 6 ?� / required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 0 G GU !/�� � �rG / W ~ �✓ �J'Tir SK Tart �b.� - (`7 20>oS /G x.?o x 0 Number of current residents: �— _/"" Does residence have a garbage grinder? El Yes L7 N'o Is laundry on a separate sewage system? (Include laundry system inspection [] Yes 3 No information in this report.) Laundry system inspected? ❑ Yes IJ''No Seasonal use? , ❑ Yes Ell' No r Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Ye Cl No Last date of occupancy: Da to Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes C] No Water meter readings, if available: c5ire•an s Tile 5 OMcid impacdm Form Subsufece Sewage oisposei Stem-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Al��7l�; On rter ON Hers Name information is required for every page Cly/Town State Zip code Date of spectlon 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 13- No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of SyrSWM: [� 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/Altemative 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): tSns-3113 1'1ae 5officia ire peceon Form Subslrfece Sewa9eDi9po%t System-Page 8of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow ner pw ner's Name J information is 7e✓!ir Ile- lea?6 .� � `� Ll'�- required for every page. Oty/Town State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components, date installed (if known) and source of information: C)o — 'j'C Were sewage odors detected when arriving at the site? ❑ Yes No� Building Sewer(locate on site plan): Depth below grade: /� -- feet Material of construction: r ❑ cast iron 0 0 PVC CJ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: Lam'COncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: — Sludge depth: 15no•3H 3 Tide 5 Offiaal lre pec ban Form SutskOwe Sewage Dlsposel System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments I l PropertyOJ � ✓1 c i Property Address ���— Ow ner ON ner's Nameirtformbon is / required for every owe le page. Cftyli'own State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) js- 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 8 (/ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? jeV16 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): u v1r j I✓1 o 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 Ora•3h3 Tine SCOCid Iru pectlm f am Sub9u'f9ce Sevaga pisposal Syuam•Page 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y Property Address u"i VVI/ 1� inf ner tlon CW ner s Name //� 11T requir dfo is Ceti /�� I i/ requ�ed for every Page City/Town State Zip Code Date 6f 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, a\Adence of leakage, etc.): Tight or Voiding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth taelow 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 woridng 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 t5im-3%3 Me50MMI Inspmbon Form SubsWace$evmgeDisposM System•PMe 11 d 17 i t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forst -Not for Voluntary Assessments Property Address e ✓1 V"-1 I aN ner Owner's Name information is Ceo �✓yl required for every -" State Zip Date of I spec ion page. 5t fTown 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.): -,w so/�s _ Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption system (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ns 3M3 rileSOMbal irtspecbenFor[Subsurface Sewage Disposal System-Page 120f 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System trorm -Not for Voluntary Assessments Property Address /7k V11 VM Cw ner Cw nees Na y� requir ed atlfo is for me on �Q�+ ,i yi/ 1 /'/�j O o) equ� Me. City/Tawn State Zip Code Date Of Inspection D. System Information (cost.) _ Type: �U�(� ' 10 .X 3C ,;4 ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ---- ❑ leaching trenches number, length: -- ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altematire system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): S�c�lrt 2 G yr C 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 t5ns'Y13 Tibe6Off6al Ins pee titnPorm Su6sxrfaoe Sawape0ieposal Sysaim•Pepe 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / Property Address / e vvv?' ON re Ow ner's Name infomation is. requvedforevery P v'���� page. Cky/Town state Zip Code Dat of Inspection D. System Information (cant.) 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.): t5lns•3M3 Tile50fedal Iris pacumForm Subsuface Sewageolsposal Syswm•Page 14 d 17 Commonwealth of Massachusetts RUEEiREM Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 S / /�/' // 02c-j Property Address Ow ner O,v ner s Nameinfon is requir�ediforevery Ce Vvo Ile page. C+Ryrrown State Zip Cade —Date—offInn-sWtion D. System Information (cont.) Sketch Of Sewage Disposal System; Pro%ide a view of the sewage disposal system, including ties to at least t p,-p6manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu&ic water supply enters the building. Check one of the boxes below. i © hand-sketch in the area below ❑ drawing attached separately �oN � 9 i� _. 7 j. t5ns•W13 Title 50fficiaf Impec Nan Form Subs Ow*Sowago Disposa system-Page 15 d 17 f Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments sw 1 0 S 14, Property Address innffomiation is ner ON ner s Name �er/y� (� / r� �o required forevery (-� c� page. CkyyfTown State Zip Code Date of I spec ion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells X2) r 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 4ard of Health- explain: 7'L- ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must descgb� ,how you established the high ground water elevation: {'i.0 11 - T`� l� ' �io �p V✓' �U-.mod-.�i- Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSm Y13 rite 53mcial Inspec6onForm SubsWxee Savage Disposal S)atem-Page 16 d 17 Commonweatth of Massachusetts viTitle 5 Official Inspection Form �tk,4 — �/ Subsurface sewage Disposal System Form - Not for VoWntary Assessments Property Address Ow ner Cw roWs Marne / J infomiOm is G ///7 required for every (�P^ ✓✓� e �. ...... page, �yfrown State Zip Code we Of Inspection E. Report Completeness Checklist "Pection Summary: A, B, C, D, or E checked "pection Summary D(System Failure Criteria Applicable to All Systems)completed C S em htrmation-Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file dm•3M3 rioe5of6ew MpeeswForfn SuW0aw Sa*"e0zpoad SyMm•Page 17 of 17 LocA'OON Gl vi f er y��1�;;•, �SS�It'S MAP�i 1LQ'x nt LAOA: . D�STP LF kt'S NANlF�PRO N - 777 i. Q ®ia odi FLRMI(T�3 .T ' �t3ivQ'°C.TA►tt DR'I'!~ ....::.-.�. ..._.....„:.` S�p�rataon�tsi Sstviee�5��; I+�sacimum;Adiusbetl mon cSw�ter'Cable Ca tho 8dapi 0 4ghW8 Rou iky 1'r1v2�8�U �tcculy W �l��cl tcaa4ing l�acdiry iY w�tls nits! nn a�t�ae within?BOO feint ui:t�aciiit►�f�cilit}�) c�ifll�t9aiid 1.anti lLoclhing Pacallty luny wetlands esc 1+114t 1n QQ Let fr leading f V. . -1 r Cvrnisltci y `. 1 - P ,�ram- �. ._ � � � �' '. ��, ♦� ,4 �°\� N a , a n M y _ , Y 1. .. .. y W ' t v , + .^ -µ • az, ' . n 4 . -v - oaf _ t i 3 a f ,a � r•a.. � V t t 4•„Y�� ��a � ;,� � � ~ � `a�i � i n .. ,, a d. SHALL TE SYSTEM PROFILE MARK DS WITHC MAGNETIC TTAPE ORBE NOTES COMPARABLE MEANS FOR FUTURE LOCATION. Zi PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) 1. DATUM IS APPROX. NGVD C 3 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING ` Exit \ TOP FOUND. EL 54.7' #6 Eli] .75' OF COVER OVER PRECAST 2% SL017 REQUIRED OVER SYSTEM 53.0 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. o� Roy{e 6 Rd 4. DESIGN LOADING FOR ALL PROPOSED PRECAST Service Coves" D7 UNITS TO BE AASHO H-Q 4"OSCH40 PVC 2" DOUBLE WASHIrD PEASTONE PIPES LEVEL 1ST 2' OR GEOTEXTIIE FABRIC 5. PIPE JOINTS TO BE MADE WATERTIGHT. ' 50.4 *51 .5f 10" 1500 GAL H-10 14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Locus WITH (PROP 51 .06' TEE SEPTIC TANK TEE 50.81 " 0 49 9, 08 310 CMR 15.000 (TITLE V.) MIN. 6 SUMP o 0 GAS BAFFLE::; juoovoo�00'000'00-00 12" MIN. INT. DIM. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND / Wequaquet 4' LIQ. LEVEL (ACME OR EQUAL) ' 5 49.93' 9992. �`� 47.9 NOT TO BE USED FOR LOT LINE STAKING OR ANY � � Lake OTHER PURPOSE. z 000000000000 0 000 � IN' LTRATORS Jp 000000000000000000000000 0 0 000000000 0000p0p0 00p0 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.p 0000000000000 .aC /A l V V__ J 3/4" TO 1 1/2" DCUBLE WASHED STONE c 9. COMPONENTS NOT TO BE BACKFILLED OR 6" CRUSHED STONE OR MECHANICAL � CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [21) OVERALL DIMENSIONS TO OUTSID" OF STONE: 30.4' X 10.25' S, HEALTH AND PERMISSION OBTAINED FROM BOARD 0 0r OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR( 3.4% SLOPE) ( 7 % SLOPE) ( 1 % SLOPE) CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND & FOUNDATION 13' SEPTIC TANK 10' D' BOX 5' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE FACILITY BOTTOM 1H-1 & TH-2 42.9 WORK. NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 193 PARCEL 26 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL SHALL BE REMOVED 5' BENEATH AND AROUND THE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PROPOSED LEACHING FACILITY. LOCUS IS WITHIN GP AND ESTUARINE PROTECTION PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 12. EXISTING LEACHING FACILITY SHALL BE PUMPED DISTRICTS LEGENDAND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. NO CONSTRUCTION PROPOSED 99- EXISTING CONTOUR X 99.1 EXIST. SPOT ELEV. 41. 99 PROPOSED CONTOUR 19 SYSTEM DESIGN: 198.41 PROPOSED SPOT EL. 39.21 41 WF 1 TH1 39.63 /' GARBAGE DISPOSER IS NOT ALLOWED TEST HOLE 4•••1 2 BEDROOMS ® 110 GPD 220 GPD 42.43 �3 = 40 •� / 44 DESIGN FLOW: _ WF 3 �ANp 2� SLOPE OF GROUND -42' � �s 2 USE A 220 GPD DESIGN FLOW \ C-0b UTILITY POLE ----43 A LOT 5 -44 6\ SEPTIC TANK: 220 GPD (2) = 440 FIRE HYDRANT 13,040 SFt --45 \ USE A 1500 GAL. SEPTIC TANK NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 47U LEACHING: -48 �9 SIDES: 2 (30.4 +10.25) 2 (.74) = 120 GPD _ \ TEST HOLE LOGS -509 5244 �o� BOTTOM 30.4 x 10.25 (.74) = 230 GPD -51 s CAUTION - GASLINE ARNE H. OJALA PE SE -52 - �� NOTE: LINE WAS FLAGGED TOTAL: 473 S.F. 350 GPD ENGINEER: ' , +52.50 sHED s PARTIALLY OFF-LOT WITNESS: DAVID W. STANTON, RS 5�58- - -- 3-3-A52.5, 2� DATE: AUGUST 21, 2009 53.92 5 USE (4) H-20 3050 INFILTRATORS, ._2 +52.83 3.40 WITH 1' STONE AT ENDS AND 3' AT SIDES 53.0 PERC. RATE _ < 2 MIN/INCH 530 s� PAVED 5 9 53.0 53.04 GAS +52.5 II IVE 53 53.33 ETER }53.18 L 53.34 CLASS I SOILS P# 12672 (JA X /+ss13 ° DECK - 53. 1 �53.11 ' +53.33•J ' 53.21 . 8 4 ELEV. ELEV. i +53.54 EXISTING 5314 APPROVED DATE BOARD OF HEALTH ' MA p" _ 53.4' 0" `V 53.4' x 1 DWELLING TOP FNDN. A A � ELEV. = 54.T � sz.s8 PROP. RE-ROUTED sL sL 53.a5 �i , - 5 53.°° / / PLUMBING TITLE 5 SITE PLAN 1 OYR 5/2 1 OYR 5/2 }53.29 I a ` �y40 / BENCHMARK OF 9„ $" s .z4.• COR BRICK LANDING ` n ELEV. = 55.0' 541 SHOOT FLYING HILL ROAD B B I 53.95 f�~ CENTERVILLE LS LS I +53 2 53.76 53. 3� ••-_•• 00 0 � CJl 1OYR 6/6 1OYR 6/6 1 N3 +50.43 36" 50.4' 33" 0.65' � H2 PREPARED FOR PROPOSED 52.74 2. 16 52.74 LOCATED WATERLINE 53.24 BORTOLOTTI CONST./HEMMILA WATERLINE c„ 1 +s I 11 (�� C C PERC SPRUCE c , 52.82 DATE: AUGUST 21, 2009 t ,. a 53.0A , o cO REVISED: SEPTEMBER 4, 2009 (2 BEDROOM DESIGN FLOW) MCS MCS 00 R= =50.73 . - -�F 50.21 .82 54.51 _ 5gpp 1 97 - - +50 _ 49.53 52 49.61 - - SIDE 2.5Y 6/4 2.5Y 6/4 s - - - R VA OF Sq r off 508-362-4 541 50 49.78 _117 fax 508-362-98800AD DANIEL downcape.com49 NG HILLDANIEL A. 00TF�"'(I oJALA OJALASH ering, CIVIL >" �,Na40980 doW/1 cope ne engi /dc. 126 42.9 126 42.9 I: 48.43 � �� civil engineers Scale: 1"= 20' °TF >�srEa��� a ✓ su wE °.. NO GROUNDWATER ENCOUNTERED s L � land Surveyors " -- 939 Main Street ( Rte 6A) 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 09- > 80 09-180 BORTOLOTTI HEMMILA.DWG