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HomeMy WebLinkAbout0086 SHORT BEACH ROAD - Health 86 Short Beach Road Centerville A=206-124 r i SMEAD No.2-153LOR UPC 12534 amaad-com • Made In USA RitU�NlliNmlR7tM LFI OF M V REPLACE THIS SLIDING DOOR WITH A LARGER DOOR(9'HAXJ LIVING ROOM LIVING ROOM ATTACHED DETAIL STALL PORTAL FRAME PER O HEV 4X6 POST O 30'SOTO NEW FODTIHG D �(3) FLOOR REAR 4 (3J 1 3/9 9 1/9 REPLACE VIHDOW WITH SLIDING DOOR lVl AROVE TD INSTALL PORTAL FRAME PER DINING ROOM KITCHEN ATTACH 5/8 PLY VOOO ELIMINATE THIS ATTACHED DETAIL TO THIS WALL WITH COLUMN IOC.NAILS AT 4-O.C. THEN REPLACE GYPSUM BOARD REMOVE THIS WALL REF p ADDl FLOOR eEAN 2 v _MEV 3x3 STEEL POST ]W.- ILA'T'.'.'N DOWN TO FOUNDATION HEW 3.3 STEUOVM TO FOUREPLACE THIS SLIDING DOORDEN WITH A LARGER DOOR(9'MAXJ INSTALL PORTAL FRAME PER ATTACHED DETAIL 12 o GARAGE 12 GARAGE EXISTING CONDITIONS PROPOSED CONSTRUCTION �y111 OFA4/S� IC E`G VIR a.a CFO/STE�q MVA ENGINEERING COMPANY ERNENWEIN RESIDENCE RENOVATIONS 633 MAIN STREET S_ DESIGN:MOM SHREWSBURY, MASSACHUSETTS 01545 86 SHORT BEACH ROAD DRAFT:MDM BARNSTABLE. MASSACHUSETTS DATE:2 20 18 PH 508 845 7800 Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z.. M ,at 86 Short Beach Road Property Address h—� Charles& Margo Pisacano Owner Owner's Name � information is required for every Centerville ✓ Ma 02632 1,2/31/2016 page. City/Town State Zip Code Date of Inspection R7 PIZ Sag Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information (� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Q Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 12/31/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name required fo is Centerville Ma 02632 12/31/2016 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 86 Short Beach Rd. is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 2 leaching trenches. The system was found to be in proper working condition at the time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface.Sewage.Disposal System Form Not for Voluntary Assessments 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts H . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments yy 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. CityrTown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form m Subsurface-Sewage Disposal System Form -_Not.for Voluntary Assessments 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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: l5ins•3/13 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 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Short Beach Road Property Address Charles &Margo Pisacano Owner Owners Name information is required for every Centerville Ma 02632 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins•3/13 Tide 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 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 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 3" Scum thickness 3" 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 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was slightly below outlet, most likely from evaporation. Tank was structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 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 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.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. 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): h If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Short Beach Road Property Address Charles &Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2x40' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology.- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 leach trenches. Soil and stone was dry with no sign of past saturation. Vegetation was normal. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M yvy� 86 Short Beach Road Property Address Charles& Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 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 r � I3 I � 2 � 3 13 g-Z 2v 6-� 33' t5ins•3/13 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..�' 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is required for every Centerville Ma 02632 12/31/2016 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: 66"tee" 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: A hand augered test hole was performed to observed groundwater elevation. Groundwater was encountered at 78". Bottom of leaching facility is 36" below grade leaving a seperation of 42". Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 86 Short Beach Road Property Address Charles & Margo Pisacano Owner Owner's Name information is Centerville Ma 02632 12/31/2016 required for every 'i page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts ---° Title 5 official Inspection_ _ Form , r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address `� �' C Owner Owners Name + S• A information is i required for C-I': •✓ 7 t; R ,ce! /(t" every page. Citylfown �Co S 3 ice State Zip Code Date of Inspection ! Inspection results must be submitted on this form.Inspection forms may not be altere In any way. Important: 1 General eneral Information When filling out A '--=---- forms on the , computer,use only thtab key Inspector � I ! to move your cursor-do not use the relum Name or Inspector i key. Compan,Y Address j h/y.A �✓Av d s I I Cltylrown .2. 41� Slate Zip Code i d 77 � � 3 Ga_ s- S Telephone Number License Number i B. Certification 1 I certify that I have personally inspected the sewage disposal system at this address and that V le ,( 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 o on 'ite sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15. 40 �f Title 5(310 CMR 15.000).The system: Q I Passes i ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1j 3 pec rs signatures Date The system inspector shall submit a copy of this inspection report to the Approving Authorit Bo l rd of Health or DEP)within 30 days of completing this inspection.If the system is a shared sys em a has a design flow of 10,000 gpd or greater,the inspector and theor system owner shall submi e report to the appropriate regional office of the DEP.The original should be sent tothe sys e;,t owner and copies sent to the buyer,if applicably,and the approving authority. I ****This report only describes conditions at the time of inspection and under the conditio' s 01 use at that time.Thislinspection does not address how the system will perform in the futt� a un the same or different conditions of use. der r �D Mnsp.doc•08N0 Tide 6 Oflidar inspection Form:Subsurface Sewage oes 1 system•Pago t dot t9 ( V t Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � G fLT Properly Address ! I r � i information is Owners Name required for � every page_ CIty/Town tState Zip Co Code Date of Inspection I B. Certification (cons) I Inspection Summary:Check A,B,C,D or E l always complete all of Section D ' i A) System Passes: I have not found any information which indicates that any of the failure criteria teria describ I in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are f indicated below. 1 Comments: B) System Co tionally Passes: I ❑ One or more stem components as des cri d in the"Conditional Pass"section need o be replaced or'tep 'red.The system,upon mpletion of the replacement or repair,as ap`roved by the Board of Hea ,will pass. Answer yes, no or not de rmined(Y, D)in the for the following statements. If"not determined,"please explai i ❑ The septic tank is metal an er 20 years old*or the septic tank(whether metal or no f)is structurally unsound,exhi ' ubstantial infiltration or exfiltration or tank failure is immi ent! System will pass insp ' n if th existing tank is replaced with a complying septic tan ;as ; approved by the Boa of Health. *A metal se;tic k will '•A pass inspe n if it is structurally sound, not leaking and if a C ertificate of Compliance' dicating that the tank i less than 20 years old is available. ND Explain: i i l P h lObservation 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. S stem will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ! L57nspdac-Oslo6 III Tian 5Okla!Inspection Form:subsodam sowase Disposal syslen; Paso 2 of 15 I I i I i Cornmonweaith of Massachusetts i -- � Title 5 Official Inspection Form Subsurface Sewage I , _ / ge Disposal System Form-Not for Voluntary Assessments # a T l?g ge__ I Prope Address Owner ,C, 4 ✓r- j information is Owner's Name required for every Page- C tylrown `/� t2( L, -OP—Code Date of Inspection B. Certj ' ation (cont.) B) System nditionally Passes(cont): i ❑ distn ution box is leveled or replaced j ND Explain: I I ❑ The system required pum 'ng more an 4 times a year due to broken or obstructed + system will pass inspection (with proval of the Board of Health): p Pe(s�•The ❑ broken pipe(s)are rep d i f ❑ obstruction is remove ND Explain: I i i i C) Further Evaluatio is Required by the Boa of Health: ❑ Conditions exist hich require further evaluation y the Board of Health in order to det rmi I if the system is ing to protect public health,safe or the environment. 1. System ' II pass unless Board of Health dete ines in accordance with 31 15.3030)(b -that the 0 system is not functioning in a anner which wit h'a1th, safety an he environment: !protect 0 M ❑ esspool or privy is within 50 feet of a surface wa r f ❑ Cesspool or privy is within 50 feet of a bordering veg tated wetland or a salt m rsh j ?. ystem will fait unless the Board of Health(and Public ater Supplier, if any) termines that the system is functioning in a manner that otects the public he lth, afety and environment: ❑ The system has a septic tank and soil absorption system( AS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply. i ❑ The system has a septic tank and SAS and the SAS is witht a Zone 1 of a pub is w I ter supply: ❑ The system has a septic tank and SAS and the SAS is within 0 feet of a privat water supply well. mnsp doc-Gwr? 1 TNe S 0fik l/nspeeBon FO JM:SubsudacD Sowago oi,posal Syslnm Papo 3 of 15 I 7 Commonwealth of Massachusetts -, Title 51Official Inspection Subsurface Sewage Disposal �n Form P System Form-Not for Voluntary Assessments ds Property f%ddress '9 42 S / / / i Ovmer I Owner's Name 1v < <S �C ��✓ ' information is // t required for r it N r £ i v P every page. City/Town State '? l Zip Code Date.of Inspection B. Certification (cons) i C} Further Evaluation !,squired by the Board of Health(c ): ❑ The system has a se 'c tank and SAS and the SA less than 100 feet but 50 feet r f more from a private--* upply welt** Method used to determine distan - I i ` '*This systems passes if the well ater analysis, rformed at a DEP certified laboratory,f r coif bacteria indicates absent and a presence orm of amm ' less than 5 ppriz,provided t no other failure criteria ton nitrogen er and nitrate nitrogen is eq al to or attached to this fiorm. triggered.A copy of the analysis must be I Other: s I i 1 i D) System Failure Criteria Applicable to All Systems: j i You must indicate"Yes"or"No"to each of the following for all inspections: i Yes No i ❑ Backup of sewage into facility orsystem component due to overtoade, or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surfac due to an overloaded or clogged SAS or cesspool w aters (� Static liquid level in the distribution box above outlet invert due to an o e o' ded slow invert or available rl or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6"b ' than%day flow volu a is less ❑ Required pumping more than 4 times in the last ear N p ( ) Y OT due to clogged or p obstructed i e s.Number of times pumped: _ Any portion of the SAS, or cesspool privy p P rry is below high ground water a evation. Any portion of cesspool or privy is within 100 feet of a surface water su t tributary to a surface water supply. ply or 65insP.doc-0&06 TT0a5 official fnsPedion FOnn:Su6wrfaco somSo Disposal System-Papo a of 15 i i Commonwealth of Massachusetts Title 5 Offic"al Inspection F i Subsurface Sewage Disposal System Form-Not for Voluntary r � tary Assessments Property Address Owner information is owners Name 1 required for T a Z? r ' v! every page. Cdy/Town State Zip Code Date of Inspection b. Certification (cont.) D) System'Failure Criteria Applicable to All Systems(cunt.): Yes No 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�well. P water supply Any porbon of a cesspool or privy is less than 100 feet but greater t an 50 feet from a private water supply well with no acceptable water quality an fysi�. [This system passes if the well water analysis,performed at a DEP crttfied laboratory,for fecal coliform bacteria indicates absent and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less tha 5(rpm, Provided that no otherfailure criteria are triggered.A copy of t e analysis and chain of custody must be attached to this form.j ❑ j The system is a cesspool serving a facility with a design flow of 200 ' / 10,0009pd. gpd= ❑ ,Y��/j The system fails.I have determined that one or more of the above ilure criteria exist as described in 310 CMR 15.303,therefore the systemils. oard a �he system owner should contact the B of Health to determine what ill be necessary to correct the failure. E Large Systems: 1 9 y .To be considered a large system the system design flow of 16,0 gpd to 15,000 gpd. must serve a facility w th a For large systems,you st indicate either or"no"to each of the following,in additio to t' questions in Section D. he Yes No13 i i ❑ the sys is within 400 feet of a surface drinking water supply ❑ ❑ th ystem i within 200 feet of a tributary to a surface drinking water uppiy ❑ ❑ the system is 1 cared in a nitrogen sensitive area (Interim Wellhead P otecfion Area—iWPA)o a mapped Zone Ii of a public water supply well If you have nswered"yes"to any qu on in Section E the system is considered a significant t `.reat or answ ed'yes"ih Section D above th large system has failed.The owner or operator o anytar e syste considered a significant threat Und Section E or failed under Section D shall upgr de toe e 9 sys m in accordance with 310 CMR 15.304. a system owner should contact the approp ate regional office of the Department. 15insp.doc-0U100 rile501rdWin9peclon Form:Subsudaco Sewage 0isposalSystom page 5 of 15 commonwealth of Massachusetts Title 51 Official Inspection F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v. Fm � S�a n T LT A c /f �e7 Address 6'< Owner /� 'q 2 4 information is Owners Name required for C4 r-T every page. LILY/iown i c) State — u l Ile) I Zip Code Date of inspection C. Checklisfi I Check if the following have been done.You must indicate"yes'or'no'as to each of the olio ing: ❑ �❑ Pumping information was provided by the owner, occupant,or Board f H alth Were any of the system components pumped out in the previous two ee ? s. ❑ Has the system received normal flows in the previous two week perio ? ❑ Have large volumes of water been introduced to th this inspection? a system recently r as part of ❑ Were as built plans of the system obtained and examined? available note as NIA) y (If they w re not ❑ Was the facility or dwelling inspected for signs of sewage back u 4 ?p �❑ Was the site inspected for signs of break out? '❑ ? Were all sy stem components,excluding the SAS,located on site? ❑ Were the septic tank manholes uncovered,opened,and the interior of the t nk inspected for the condition of the baffles or tees,material of constructi n, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provide with information on the proper maintenance of subsurface sewage disposal syst�ms? The size and location of the Soil Absorption System(SAS)on the ite h s been determined based on: ❑ Existing information.For example, p ,a Plana e Board of Health. [] ❑ Determined in the field(if any of the failure approximation of distance is unacceptable)1310 CMR 15.302(5)) C is t iss i e Mnsp.dcc.00/U6 TiUe 5 ofr1cW 1-W tae Famr Subsurface Sm.,,ce olsposal System•pace 0 f t 5 I Commonwealth of Massachusetts Title 5 4ffic6al Inspection Form Subsurface Sewage Disposal,System Form-Not for Voluntary Assessments Property Addr s , Owner Owner's Name information is required for v every page. Utyffown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): -- -- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110gpdx#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ es ( No Is laundry on a separate sewage system? if yes separate inspection required] ❑ les 2-- o Laundry system inspected? ❑ Y as I❑ No Seasonal use? I as W No Water meter readings,if available(last 2 years usage(gpd)): Sump pump? ❑ Y ' No Last date of occupancy: Calp D e Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): I Gallons per day(gpd) Basis of design flo seats/persons/sq.ft., c.): Grease trap present? ` ❑ Ys ❑ No I Industrial waste holding nk prese ? ❑ Ys No 9 Non-sanitary waste dischar o the Title 5 system?y ❑ Y4s ❑ No Water meter readings,if a flab I I Last date of occupanc use: Date Other(describe)_. Mnsp.doc-0ero5 Tipe5 Mal Insped fon Form:Subsurface Sawage Disposal sync -Pago 7 of 15 i I commonwealth of Massachusetts _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PropeP Address A /L Owner CA �� �9�/a ,2 Owner's Name i information is r required for C9 A--T .C!: �� � ./d _ C" j O every page. Citylrown State 62 / Zip Code Date of inspection D. System Information (cons.) I I Genera!Information Pumping Records: Source of information: U 6e " t sv Was system pumped as part of the inspection? ❑ Yes N 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 an ) ❑ Innovative/Aitemative technology.Attach a copy of the current operation at ld maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. 0 Other(describe): 1 Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No I l5fnspdoa-08ros T"05 0flkW irspaction Form_Subsurface Se%vago oi$posol Systmn Page a or t5 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . � Property Address ,A Lj / S rF f} Owner Owner's Name information is required for �6 Z ti 7—e i v y le / I every page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: / . feet Material of construction: ❑cast iron 40 PVC ❑other(explain): Distance fromprivate 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: concrete ❑metal ❑fiberglass r9 El Polyethylene ❑ oth r(e)plain) If tank is metal,list age: ~� years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑❑ Ye - - - - --------------------------------------------------------------------- - - No--- Dimensions: �1 S� ( Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 3 ) Scum thickness I ` I Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle l 3 How were dimensions determined? 01 E9 A s 0 15615p.d=-06f06 TIb 5 of''CW Insppebn Form:Subsurface Sewage 019p0301 Sys10 .Pag 9 01 15 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewa a Disposal System For Voluntary -Not for Volunm Assessments c � _ Pro a Add(A IL//� Owner �` A' �- 17 �S��C;a ,�.� 0Owner's Name information is required for C a? .v T 6L vi /lam CQ 3a every page. Citylrown State v Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle co ' liquid levels as related to outlet invert,evidence of leakage,etc.): ndtiton,structu al integrity, Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ncrete El metal ❑fiberglass ❑polyethylene jothr ): Di nsions: Scum ickness Distan a from top o m to top of outlet tee or baffle Distanc from bo m o cum to bottom of outlet tee or baffle I Date of ast pu ping: , Date COmme tS ( pumping recom endations,inlet and outlet tee or baffle conditior t g liquid level as related to outlet in rt,evidence of leakage,etc.): n,structu I in rity, i Tight or Holding Tank(tank m e pump at ti e of inspection) (locate on site plan): i Depth below grade: Material of constru 'on: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑othe;(ex lain): 15insp.doc-0e 06 Tt095ORkW inWdien Fond:Subsudaco Satrdge Disposal syslom•page 00i 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner A !L A S' ct' Owner's Name information is required for C'E /A- every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight olding Tank(cont.) Dimensions: Capacity: gallons I Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of[as umping: � Date Com nts(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required).is copy attached? ❑ Yes '❑ No Distribution Box(if present must be opened)(locate on site plan): /i Depth of liquid level above outlet invert © Comments(note it box is level and distribution to outlets equal,any evidence of solids ca love i,any evidence of leakage into or out of box,etc.): R /2 Pump Chamb ( cate on site pl Pumps in wo in der: El Yes ❑ No Alarms in working o ❑ Yes ❑ No I tSGnp.doc.Was TiUe50UkWInspeetionFaun:Subsuifaco Sewage oisposatSystom;page1 ofi5 i Commonwealth of Massachusetts Title `5 Official lnspecti®n Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro arY Address Owner Owner's Name information is P �2 required for _� '✓7 9 n /// J ®� G�C c= every page. Cltylrown State Zip Code Datd of Inspection D. System';Information (cont.) Comments(note condition of pu hamber,condition of pumps and appurtenances,etc.): I Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number_ ❑ i leaching chambers number_ ❑ ; leaching galleries number. leaching trenches number, length: .._. ❑ ; leachingfields numb er,dimensions: ❑ overflow cesspool number. f ❑ innovativelaltemative system Type/name of technology: Comments(mite condition of soil,signs of hydraulic failure,level of ponding,damp soil,co ditio of vegetation,etc.): SAT 13O,1`1'pah ''opt �� I 156wpdot•g8l08 line 6 oBidal Inspeden Form:Subsurface Sewage Olsposal System•page 12 0115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 441 `/ Property ddress Owner Owner's Name information is required for �E T&Z 2 every page. City/Town State Zip Code Date of Inspection D. System Info rmation ormation (cons) Cesspools(cesspool ust be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet in rt Depth of solidshayer Depth of scum layer Dimensions of cesspool Materials of corstru ' n Indication of gr , ndwater inflow El Yes ❑ N Commen note condition of soil,signs o ydraulic failure,level of ponding,condition of ge tion, etc.): I Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note ` ndition of il,signs of hydraulic failure,level of ponding, condition of v `get Lion, etc.): u�.�oc•geese Me 5OR W tmpod►en Form:Subsurface Sovrage Oispasai Sysrom Pago 3 of 15 Commonwealth of Massachusetts _ - Tltle 5 official Form Inspection F ' p ' Subsurface Sewa a Dfsposat System Form-Not for Voluntary Assessments PtoptAddress nle- Owner Owners Name ' -- C 'ram�' information is required for every page. Ci frown Statekak Zip Code Date Inspect(.: D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system in udin ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 10 fee Locate where public water supply enters the building. �0 � / r� Q a.l 03 - - �2 O 13 ` 3 - 3.3 � �nspdce-08106 MO S OMCW I-POW-F—:SUbsu a Snvrago olsPnsal Sys1a =Pagu 4 0!15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewa a Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is /- required for t (/C `.. every page. -wi l own State Zip Code `3 —0 f Da of Inspection 71i D. System Information (cons) Site Exam: . 0 Check slope /;��Ilp 7- 0--Surface water D/Z. heck cellar OR shallow wells A-"Q"� Estimated depth to ground water. 3 feet Please indicate all methods used to determine the high ground water elevation: i ❑ 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: �o r 7-c) �,q $ .���6L� T i vim✓ 5--e e L%sp doc•08(06 77005011ial tnspectim Form:Subsurface sewago Orsposai system Pago 5 of f5 r COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE;OFFICE OF;ENVIRONMENTAL AFFAIRS DEPAKTMENT 0F'ENVIRONMENTAL PROTECTION, RECEIVED NOV 2 1200 -TOWN OF BARNSTABLE. TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ CERTIFICATION Property Address: 86 Short Beach Rd`: ®r„ Centerville. MA 02632 Owner's Name: Victor Bennett PARCEL ' Owner's Address: Same � - LO7 Date of Inspection:_ J /S`—a Name of Inspector:(please print) Wi 1 1 i am E_ . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: "P O Box 1089 Centerville; MA Telephone Number: (508) 775-8776 l CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)." The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthlor 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 approxing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM NOT`FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address. 86 Short Beach Rd Centerville MA 02632 Owner. Bennett ` u _ Date of inspection: Inspectio Summa Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: 1 have not found any information which indicates of evaluated arhat any of the e tlure indicatederia below described in 310 CMR pl 15.303 or in 310 CMR 15.304 exist.Any failure criteria n Comments:.._ +� B. Sy tem Conditionally Passes: d or ne or more system components as described in the"Copnditionalp razov'ed b tion.need to be re the Board of Health ewill pass. repaired The system,upon completion of the replacement or re air,asap y Answer s,no or not determined(Y,N,ND)in the for the following statements.If ,not determined"piease explain. Th D septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent,System will pass inspection if the existing t ink is replaced with a complying septic tank as approved by the Board'of Health. •A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND exp ain:. O servation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval o Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expla e system required pumping more than 4 taaes a year due to broken or obstructed pis).TIC system will pass in ection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed ND explain: Page 3 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART`A CERTIFICATION(continued) Property Address: 86 Short Beach Rd. Centerville, MA 02632 _ - Owner: Bennett Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system` is fail' to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310,CMR 15.303(1)(b)that the s tem is not functioning in a manner which will protect public health,safety and the,enviro.nment: Cesspool or privy is within 50 feet.of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh- 2. Syste will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the system is unetioning in a manner that protects fhe.public health,safety and environment: _ e system has aseptic tank and soil absorption system(SAS)and the SAS.is within 100 feet of a surfa a water supply or tributary to'a surface water supply. e 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 froal a p 'vate water supply well••.Method used to determine distance •• his system passes if the well water analysis,performed at DEP certified laboratory, for coliform bac ria and volatile organic compounds indicates that the well is free from pollution from that facility and. the esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fail criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION(continued) Property Address: 86 Short Beach Rd. Centerville, MA 02632 Owner. Bennett „ Date of Inspection: D, yytem Failure Criteria applicable to all systems: ; You ust indicate"yes"or"no"to each of the following for all inspections: Yes o _ Backup of sewage into facility or system component due to overloaded or clogged SAS:i 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 iquid depth in cesspool is less than 6 below invert or available volume is less than day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s):Number f times pumped _ l or privy is below high ground water elevation. y portion of the.SAS,cesspoo _ y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. y portion of a cesspool or privy is within a Zone tl of a public well. _ y,portion of a cesspool or privy is within 50 feet of a private water supply well y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water upply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform_bacteria and volatile organic`compounds indicates that the well is free from pollution fro that facility and the presence of m ce 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.] (Yes/No)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. s• ' E. Large ystem . facility with a design flow of 10,000 gpd to 15,000 To be consi ered a large system the system must serve a gpd- You must in .cate either"yes"or"no"to each of the following: (The followin criteria apply to large systems in addition to the criteria above) yes no the s tem is within 400 feet of a surface drinking water supply the sys em is within 200 feet of a tributary.to a surface drinking water supply _ the syst m is located in a nitrogen sensitive area(Interim Wellhead Protection Area_ WPA I ) or a mapped Zone II f a public water supply well If you have answer d"yes"to any question in Section E the system is c�sidered a significant threat,or answered "yes'in Section D bove the large system has fwkd.The awriff or operator of any large system considered a significant threat u der 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. 4 Page 5 of 1 I ' ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEVd/AGE AIs DISPOS SYSTEM INSPECTION FORM .t4' ' ' PART B t CHECKLIST' Property Address: 86 Short Beach Rd. en ervi e, !7 2632 Owner: Bennett Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ izPumping information was provided by the owner,occupant,or Board of Health; V Wcre any of the system components pumped out in the previous two weeks? _ _✓ Has the system received normal flows in the previous two week period,? I 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 41 1/ / Was the site inspected for signs of break out.? v Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ —/Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems?_ The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no/ . Existing information.For example,a plan at the Board of Health. _ Determined in the field if an of the failure_ ( y criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of l 1 OFFICIAL_INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION Property Address: 86 Short Beach Rd. _ Centerville, MA 02632 Owner: Bennett ,-. .. Date of Inspection: - d 2-- FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 5.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage der(yes or no): _ Is laundry on a separate sewage system(yes or no):�d[if yes separate inspection required] Laundry system inspected(yes or'no): Seasonal use:(yes or no): 3 Water meter readings,if available(last 2 years usage(gpd)): 01.-9 5-,0 0 0, gal. Sump pump(yes or no): �- 0 0—1 51 ,0 0 0 gal. Last date of occupancy: - COMMERC L/INDUSTRIAL Type of establi hment: Design flow( ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap esent(yes or no): Industrial w ste holding tank present(yes or no): Non- waste discharged to the Title 5 system(yes or no): Water m er readings,if available: Last dat of occupancy/use: OTH (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as paWof the inspection(yes or no): � If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM — eptic 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 contact(to be obtained from system owner) —Tight tank Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: �—r Were sewage odors detected when arriving at the site(yes or no):�i!> 6 Page 7 of I I OFFICIAL INS.PECTI.,ON FORM=NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued),:: Property Address: 86 Short Beach Rd. er i e, A 02632 Owner: Bennet Date of Inspection: BUILD G SEWER(lot:aie on site plan) Depth be ow grade: Material of construction: cast iron _40 PVC_other(explain): Distanc from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: e� Material of construction: ✓,cconcrete_metal_fiberglass_polyethylene` —other(explain) If tank is metal list age:_ is age confirmed-by med•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions: Sludge depth: O , 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 utlet tee or baffle: 3 How were dimensions determined: O ��� G n Ll z!qS 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 RAP:_(locate on site plan) Depth bel w grade:_ Material o construction:_concrete_metal_fiberglass_polyethylene_other = (explain): Dimension Scum thic ss: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last umping: Comments n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' SUBS PART C SYSTEIVM"'INFORMATION'(continued) ,:- 86 Short Beach Rd. Property Address: MA 02632 en ervi e. Owner: Bennett ; Date of Inspection: or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) TIGHT Depth below grade: of eth lene other explain): Material of construction: concrete metal fiberglass_p Y Y Dimensions: allons Capacity: allons/day Design Flow: Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(condition of larm and float switches,etc.): DISTRIBUTION BOX: /(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: any evidence of evidence of solids carryover, . Comments(note if box is level and distribution to outlets equal,any leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working or er(yes or no): Alarms in working rder(yes or no): Comments(note c ition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 { OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ._ PART C j SYSTEM INFORMATION(coptmued) Property Address: 86 Short Beach Rd. Centerville, MA 02632 Owner: Bennett Date of Inspection: ,S d7-- w ._ SOI.L ABSORPTION SYSTEM(SAS): 'V(locate on site plan,excavation. .not required) If SAS not located explain why: i Type leaching pits,number:_ leaching chambers,number: aching galleries,number: leaching trenches,number,length: / -`1YS4j?D leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative'system Type%name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): !V 7icL✓r66 1) CESSPOO S: (cesspool must be pumped as part of inspection)(locate on site plan) Number and onfguration: Depth—top o liquid to inlet invert: Depth of solid layer: . Depth of scum um Dimensions of esspool: Materials of con truction: Indication of gr dwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (1 cate on site plan) Materials of con truction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY'ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM :<.. PART C:•; . SYSTEM INFORMATION(continued) Property Address: 86 Short Beach Rd. —U—e—nEerville, MA 02632 Owner: Bennet Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent'reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the-building. 3 _ _ f L)b J 1,)0 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 Short Beach Rd. 02632 Owner: Bennett Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells L Estimated depth to ground water 7�-O—feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 61 S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must descr'be'how you established the high ground water elevation: r6 11 No....1 • 1.- ... Fmc #-f...-......�. ../........ THE COMMONWEALTH OF MASSACHUSETTS �, -r=�" BOARD OF HEALTH ..........................................O F...................................... ..---.--------......---...-------•.....-------- ,� Q A,liptiration for UiBpasal 10orku (Imitrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal �,,sow System at: 4EA� �� cJ Location-Address or Lot No. ............... ........................•- W Owner Address a .... .-. ........................................................... Installer Address U Typ of Building Size Lot_- 1�_�� ----Sq. feet Dwelling—No. of Bedroom ............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ..... _ __ ____ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) � Other fixtures -•--•-••------------•-•-•----•----------------------- W Design Flow...o.! ----------------_--___gallons per person per day. Total da'y flow__........_ �._�.._.__.__-_--_gallons. WSeptic Tank—Liquid capacity/7)gallons Length.._,_.... Widt�------- Diameter________________ nll__.___________- x Disposal Trench—No............ . . Width.................... Total Lengt...................... Total leaching area___ 6�f._...sq. ft. Seepage Pit .N �� Diameter.................... Depth below inlet............ to lea&,1n rea-- -- - •-8---..sq. ft. , Z Other Distribution box ('�1 Dosin ank ( ) /`� �'�yl• Y� ~" Percolation Test Results Performed by./________________________ ___________ ___________ ......... Date.._`��/-/�,-•__--_-______---- Test Pit No. 1................minutes per inch Depth of Test Pit .. epth to ground water-_--__-______________._. LX4 Test Pit No..2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_-_._.__________--. f� O Description of Soil °� --�---�------ :-.- -1---� - t� - ---- - �--- --_ --- ---�-�--------- -le .------. �' ` ._ _ ______ ________ W -__--_-. _______________________•-----_•____---_--------__-•----•--•-__---_--____-_-----______ o__-_--_________--_-__-_____-F----_______._ ____________________ U Nature of Repairs or Alter s An whe pli 1 .__ � _•- �; ---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu the bo d of health. :SiVne -•-------- --- . ...Da Application Approved By.......... ..... - ---•---------••----- 2te Application Disapproved for the following reasons: ---------------------------------------------------................-•------••-- Date PermitNo...............-------------------••-------------------- Issued.-----................................................. Date lop y � A No......................... Fmc.............................. ti THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ... ......... .....................OF.................................. , ppliratio t for Btspuiittt Works Tonstrurtinu 1rrmit Application is hereby made for a Permit to Construct ,( ) or Repair ( ) an Individual Sewage Disposal System at Location-Address or Lot No. �v, 1 ll 1 j Owner ' "^• Address Installer Address Type��of Building Size Lot__ . S feet q Dwelling—No. of Bedroom ..... Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building» __4�_Z: -A-�__ No. of persons____________________________ Showers ( ) — Cafeteria ( ) d Other fixtures ...................................................... W Design Flow__._.__='.� _________________________gallons per person per day. Total daily flow............................................. WSeptic Tank—Liquid capacityA-'_ .gallons Length_._,_ _______ Width-;........... Diameter---------------- De)tll__.__-__-___---- x Disposal Trench=No._________.......... Width.................... Total Length.................... Total leaching area---_ ff----sq. ft. Seepage Pit No �_0_`5rL_1�r Diameter.................... Depth below inlet..... to leacgbmg rea._ q. �� �_____s ft. Z Other Distribution box ( Dosinoank ( ) ". `'" I le 1 1 Percolation Test Results Performed by_ ---••----- Date__ --_---� a'---------------- E*'' � HTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LLi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to.ground water_-__________-_______---. ./,V-_ _... .. t D Description of Soil-- _- _ ' . i �F - -------- j - r — W UNature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________ ---------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue d by the board of health. g ' K---- f Da Application Approved By........ = •• ••-•----------•-••-•--- ---------ir...... " ------ Application Disapproved for the following reasons_........................ ' --------------••--•---------------•------------- ate.............. ----------------'-••-'-----------____-•-•-------------•-••-------'•--•-------'-----------'-•------------•------------••----------•-----•'•••------------•--------------'-•-•------•-•---------••-'•'--- Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH 7..1 ...............OF........ .. ............ u ' CIrrtiftrate of Toutplia trr T S IS'-O C TIFY, That the ndividual Sewage Disposal System constructed (: or Repaired ( ) ..... Installer 1 has been installed in accordance with the provisions of Article XI of The State Sanitary Code s described in the application for Disposal Works.Construction Permit No.-----------Ts__._.¢`�f:�_"'........ datedy--- �f �"���� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU_ ® AS A 9U#RANTEE THAT THE SYSTEM WI FU TION ATISFACTORY. DATE.......> - -- .......................... Inspector----- ................. de THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT " ..........O F...... ................. ..... ... 0..---•......................... FEE........................ Permission is hereby granted____ . _-___ _____'rk-�, ta� #rttrtt�at prlltt .. ---------------- to Cons uc or Re air n Individual Se a e D s osa ,System ( p ( ' ) A aP Y at No: 1,. o ----------- �- _ ¢ - --- Street f as shown on the application for Disposal Works Construction Permit, No-----,_-__ -------- Dated__. _-.-___- r--- L/rr Y r �1�.:/% if .f s ---- ---- ...... Vx:t+ ,Fl, „�. Board of Health DATE_. _. e6���sy FORM 1255 HOBBS & WARREN. INC.:: UBLISHERS �f ,d'W � M4e,490A f6�� `� d �I l ✓� A L/ t s 4/ 1-4 I� \ 1 M - - - � - e I � !.. � �v _ ` '� �_ _ .- - -.I E' / t �I SWo2r ij�F+c., zip � E E n / P• '1 ! ♦ 4e, PU ZC = a ! 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