HomeMy WebLinkAbout0961 SHOOTFLYING HILL RD - Health (2) 961 Shootflying Hill Road
Centerville
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INSTALLER'S NAME&PHONE NQ.
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LEACHING FACILITY:(type)�� l \ ,eX7, (size) 'Jf'eJ k 5"f`(7
NO.OF BEDROOMS
OWNER_
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) p Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7
M s 961 Shoot Flying Hill Road _
Property Address
Michael P. Brennan Jr.
Owner Owner's N
information is -a
required for every Cente ille (Barnstable) MA 02632 February 9, 2018 R ,
page. City/Town State Zip Code Date of Inspection
f*ery
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completenegs checklist at the end of the form.
Important:When A. General Information
filling out forms S1 0- 1 02a(,Q 9
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Flaherty Jr., IRS, REHS
use the return Name of Inspector
key.
Flaherty Environmental Services
Company Name
P.O. Box 81
Company Address
Yarmouth Port MA 02675
City/Town State Zip Code
774-994-1166 SI #4713
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs rther Evaluation by the Local A proving Authority,7
1
'4 February 10, 2018
Inspector's Signature Date
The system inspector shall subm/tacopy 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'< 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is required for every Centerville (Barnstable) MA 02632 February 9, 2018
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:
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
H . Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is required for every Centerville (Barnstable) MA 02632 February 9, 2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t enerve(Barnstable) MA 02632 February 9, 2018
required for every C ( ) b ry
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or.system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'rt 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is Centerville Barnstable MA 02632 February 9, 2018
required for every (Barnstable) ry
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.•°• 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t Cenerve(Barnstable) MA 02632 February required for every ( ) b ry 9 2018
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is )(required for every Centerville Barnstable MA 02632 February 9, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
/Water meter readings, if available last 2 ears usage d '16: 91 gpd; '17:
9 ( Y 9 (gpd)): 69 gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t Cenerve (Barnstable) MA 02632 February 9, 2018
required for every ( ) b ry
page. Cityrrown 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: owner, August 2016
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is t CenervillB tbl e (Barnstable) February required for every ( ) MA 02632 Fb ry 9, 2018
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:
1983 per BBOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >50
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints tight, venting through dwelling adequate, no evidence of leakage
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection( Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t Cenerve (Barnstable) MA 02632 February 2018
required for every ( ) b ry 9
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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t Cenerve(Barnstable) MA 02632 February required for every ( ) 9 2018
page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t B ill t enerve (Barnstable) February required for every C ( ) MA 02632 F rY 9, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is Centerville Barnstable MA 02632 February 9, 2018
required for every (Barnstable) ry
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leachingtrenches number, length:
� 9
❑ leaching fields number, dimensions:
® overflow cesspool number: (1)
❑ 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.):
soils sandy with gravel and some cobbles, no signs of hydraulic failure or breakout, no apparent stain
line, no liquid (dry), vegetation typical (lawn)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration (1)
Depth —top of liquid to inlet invert 24„
Depth of solids layer
4"
Depth of scum layer <1"
Dimensions of cesspool 6'W x 5'D
Materials of construction block concrete
Indication of groundwater inflow ❑ Yes ® No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is required for every Centerville(Barnstable) MA 02632 February 9, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
soils sandy with gravel and some cobbles, no signs of hydraulic failure or breakout, no apparent stain
line above liquid level, vegetation typical (lawn)
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.):
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
10 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M z 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is t ill t Cenerve(Barnstable) MA 02632 February required for every � � b ry 9 2018
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owners Name
information is bl t B ill t Cenerve(Barnstable) MA 02632 February required for every ( ) 9, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >30
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Town of Barnstable Groundwater Contour Maps indicate groundwate to be 30'-35' below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•°� 961 Shoot Flying Hill Road
Property Address
Michael P. Brennan Jr.
Owner Owner's Name
information is bl t ill t Cenerve(Barnstable) MA 02632 February 9, 2018
required for every ( ) �
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
t r
Commonwealth of Massachusetts copy
u : ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owners Name
information is Centerville
required for MA 02632 August 30, 2010
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: U
only the tab key
to move your Patrick T. Sullivan
cursor-do not use the return Name of Inspector
key. Ready Rooter, Inc.
Company Name
r� P.O. Box 371
Company Address
Sandwich MA 02563
�dpA City/Town State Zip Code
508-888-6055 SI 12843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
• sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
September 9, 2010
Inspector's Signature Date
The system inspector shall submit a copy bf this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
• at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
LA v 6
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 1 of 1
1 r
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner - Owner's Name
information is Centerville _MA 02632 August 30, 2010
required for g
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System consists of a converted cesspool and overflow cesspool
B) System Conditionally Passes:
❑ One or more system components as described in th "Conditional Pass" section need to be
replaced or repaired. The system, upon completio of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" ( , N, ND) for the following statements. If"not
determined," please explain. -
The septic tank is metal and over 20 years oI or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial inf ration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is r laced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspect' n if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank i less than 20 years old is available.
❑ Y ❑ N ❑ (Explain below): x
t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 2
a
r . e •
Commonwealth of Massachusetts
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 Au ust 30 required for g , 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break/ea
tic water level in the distribution box due
to broken or obstructed pipe(s) or due ted or uneven distribution box. System will
pass inspection if(with approval of Boa
❑ broken pipe(s) are replaced ❑ N ❑ ND (Explain below):
obstruction is removed ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or rep ❑ N -❑ ND (Explain below):
❑ The system required pumpi g more than 4 times a year due to broken or obstructed pipe(s). The
• system will pass inspectio if(with approval of the Board of Health):
❑ broken pipe(s) a replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Bo d of Health:
❑ Conditions exist which require further eva ation by the Board of Health in order to determine if
the system is failing to protect public he th, safety or the environment.
1. System will pass unless Board Health determines in accordance with 310 CMR
15.303(1)(b)that the system is no functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is wit in 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
961 Shootflying Hill Road
Property Address
• Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 2010
required for g �
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 anner that protects the public health,
safety and environment:
❑ The system has a septic tank and soi absorption system (SAS) and the SAS is within
100 feet of a surface water supply o tributary to a surface water supply.
❑ The system has a septic tank and AS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank a d SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or
more from a private water supply w II**.
• Method used to determine distanc
** This system passes if the well ter analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that 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: T
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 r
4 Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'' 961 Shootflying Hill Road
Property Address :
Gregory&Ann Toupouzis
Owner Owner's Name
information is 9
required for Centerville MA 02632 August 30 2010
every page. Cityfrown 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. -
El ® 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 i/in
ither"yes" or" "%to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the systhin 400 eet of a surface drinking water supply
❑ ❑ the systhin 0 feet of a tributary to a surface drinking water supply
' the systa d in a nitrogen sensitive area (Interim Wellhead Protection
❑ ❑ Area— I mapped Zone II of a public water supply well
If you have answered "yes"totion in Section E the system is considered a significant threat,
or answered "yes" in Section he large system has failed. The owner or operator of any large
system considered a significaunder 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.
l5ins-09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 2010
required for g
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 flow' in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
i this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
• ® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
t5os-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 2010
required for 9 ,
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
• Water meter readings, if available (last 2 years usage (gpd)): 2008=266 GPD
• 2009= 227 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Ti e 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owners Name
information is Centerville MA 02632 August 30 2010
required for g i
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i a
General Information
Pumping Records:
Source of information: Ready Rooter records: Pumped 09/08
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 600
gallons
How was quantity pumped determined? Site tube on truck
Reason for pumping: Inspection
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):
Converted cesspool and overflow cesspool.
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is 9 required for Centerville MA 02632 August 30 2010
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:
}
Home built in 1964. No records on file at Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1'8"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
•
Sept+e—Fank (locate on site plan):
Depth below grade: 1feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain)
Converted cesspool. Concrete block.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
45W X 5.VD
Sludge depth:
2" (sand bottem)
l5ins-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
t
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is g
required for Centerville MA 02632 August 30, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
34"
Scum thickness
4"
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
4
How were dimensions determined?
Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet PVC tee in place. Outlet orangeburg tee in place. Liquid level at outlet invert. Converted
cesspool pumped and cleaned during inspection. Hand augered 2' below base, no ground water
intrusion. Structurally O.K. at time of inspection. Recommend pumping yearly.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal fiberglass El polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to/bottom
tee or baffle
Distance from bottom of scumof outlet tee or baffle
• Date of last pumping: Date
i w
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is 9 required for Centerville MA 02632 August 30, 2010
every page. Citylrown State Zip Code Date of Inspection
• D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, -
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -
Material of construction:
❑ concrete ❑ metal fiberglass El polyethylene ❑ other(explain):
Dimensions:
Capacity: ./
gallons
Design Flow: gallons per day
Alarm present: ElYes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition .f alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments *
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 2010
required for 9
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet-invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No D-box.
Pump Chamber(locate on site plan):
Pumps in working order: r ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pum chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
4
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 2010
required for _ 9 ,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
'
® overflow cesspool number: 1-4'W X 5.4'D
❑ 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.):
Liquid level in concrete block overflow 2' below invert. High water staining 1'9" below invert. No sign
of past hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
' Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form g
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30 required for g , 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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 hydraulic failure, level of ponding, condition of vegetation,
etc.):
b
1
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is Centerville MA 02632 August 30, 2010
required for
every page. Cityrrown State Zip Code Date of Inspection •
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t
1
A
a
o as- ' ss `
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory &Ann Toupouzis
Owner Owner's Name
information is g
required for Centerville MA 02632 August 30 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >2
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
ma.water.usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
Hand auger 2' below base of converted cesspool showed no ground water. Accessed local ground
water contours anf topo mapping. No high ground water in area of system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
961 Shootflying Hill Road
Property Address
Gregory&Ann Toupouzis
Owner Owner's Name
information is required for Centerville MA 02632 August 30, 2010
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
LOCATION SEWAGE PERMIT NO.
- y�6 /
G E /9,
LM
TNTA LLER'S
NAME i ADDRESS
I U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
Ire
110
zs
as
ti