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Home My WebLink About0446 SOUTH MAIN STREET - Health 446 South Main Street Centerville P A = 207 005 Silt e- j", UPC 12543 `Now . WA%TINGS MN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is Centerville MA 02632 November 27 2007 required for , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: (D only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name VQ 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number i s " B. Certification I certify that I have personally inspected the sewage disposal system at this address land 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 15340 of, Title 5 (310 CMR 15.000).The system: ;f• Cj ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority W�t I 11k::)r a i--, P—� November 27, 2007 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. t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27, 2007 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2827.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is Centerville MA 02632 November 27 2007 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is Centerville MA 02632 November 27 2007 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2827.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): 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 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. t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n1a Number of bedrooms (actual): 4 (2 units) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 248 gpd ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate 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: Last date of occupancy/use: Date Other (describe): t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M10 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 11+years. Certificate of Compliance issued 817196(Board of Health permit#96-367) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3feet 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.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): 1 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: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 6 in Distance from top of sludge to bottom of outlet tee or baffle 28 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? As Built card t5-2827.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): I t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ leaching trenches number, length: ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. I t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5-2827.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is required for Centerville MA 02632 November 27, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. LOCATIONS GARAGE A g APARTMENT 1 22 f E 34 FL 2 27 f E 29 f E 3 31 fE 26 fE I ° SEPTIC TANK EXISTING 2 DWELLING 3❑ 0-BOX # 446 B LEACHING GALLERY W z J W H 3 SOUTH MAIN STREET NOT TO SCALE t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 446 South Main Street Property Address New Century Mortgage Corp. Owner Owner's Name information is Centerville MA 02632 November 27 2007 required for , every 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 ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan 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 survey instrument was used to determine that the elevation of standing water in a nearby bog was 8 feet below the bottom of the soil absorption system. Applying a groundwater adjustment of 4 feet (Index well M1 W-29, Zone B, February 2005 reading=9.7) demonstrates that the bottom of the soil absorption system is above the adjusted high groundwater elevation. t5-2827.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 P Town of Barnstable �F tHE 1p� Regulatory Services B, ,SrAB Thomas F. Geiler,Director MASS ,0g A,F019. Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations .contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. CO��ON4 HEALTH OF MASSACHUSETTS EXECumrE, OFFICE OF EN-V"IR.ONMEN-rAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIOLL RECEIVED PARCM ®� NOV 3 2004 '0T - TOWN O�H OEPTABLE TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_L(qL So �0 5-kveel Owner's Name: JU Owner's Address: Ik Date of inspection: f p 1. g 1 oq 4a 675' Name of Inspector:tplease print} i G C Company Name: Is A,% MeW wS � NS Mailing Address: a 0.j6gl Telephone Number: SOS-3 aT4—21s CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 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: !•Oak fl 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. 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 Ins ection For m rrn 6/I5/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C(q 6 `O t {Z -e Owner. a l' e Date of Inspection: Inspection Summary: Check A,%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 to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the foilowin tements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the s c tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or ex5ltration or fin-hire is imminent.System will pass inspection if the existing tank is replaced with a complying septic tmk as" oved by the Board of Health. *A metal septic tank will pass inspection if it is stru y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a le. ND explain: Observation of sewage backup out or bio static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro tiled or uneven distr>bution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)amen obsisremoved distribution box is Ieveied or replaced ND explain: _ The s in required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe on if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: yyg Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to ten-nine if the system is failing to protect public health,safety or the environment- I. System will pass unless Board of Health determines in accordance with 3 CMR 15.303(1)(b)that the stem is not functioning coning in a manger which will protect public health, .#ety 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 we and or a salt marsh 2. System will fail unless the Board of Health(and P lie Water Supplier,if any)determines that the system is functioning in a manner that protects the lie health,safety and environment: _ The system has a septic tank and soil ab tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfac ater supply. _ The system has a septic tank and S S and the SAS is within a Zone I of a public water supply. _ The system has a septic tank SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance "This system passes if well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile o anic compounds indicates that we ll eIl i P s free from pollution from that facility and the presence of nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are 'ggered.A copy of the analysis must be attached to this form. 3. Other. 3 Page 4 of l l OFFICIAL.INSPECTION FORD-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMOSAL SYSTEM INSPECTION FORM PART.A• CERTIFICATION(continued) Property Address: 144,6 wiksi- ,A Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No K 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'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pq*s).Number of times pumped L' 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis-(This system passes if the well water-analysis, performed at a DEP certified laboratory;for cam bacteria and volatile organic,compoundsindicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to,or less than 5 ppm,provided that no other 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. E. Large Systems: To be considered a large system the system mast serve a with a design flow of 10,000 gpd to 15,000 gpd- { You must indicate either"yes"or-no"to each of the owing: (The following criteria apply to large systems in on to the criteria above) yes no the system is within 400 f a surface drinking water supply the system is within 2 feet of a tributary to a surface drinking water supply the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a p 'c water supply well If you have answ "yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sectio above the large system has failed.The owner or operator of any large system considered a. significant t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.Th stem owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: sov 1 l Owner. ( AL- Date of Inspection: 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) i 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 m tenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yqs no 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 its unacceptable)[310 CUR 15.302(3)(b)) 5 Page 6 of I 1 OFFICIAL JNSPECTIQN FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:� tic{ • Owner: Z Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): Y DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): i Number of current residents: 0 Does residence have a garbage grinder(yes or no): XO Is laundry on a separate sewage system(yes or no):-?W f if yes separate inspection required] Laundry system inspected(yes or no):A0 Seasonal use:(yes or no):/_W Water meter readings,if ay4}able(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment.- Design flow(based an 310 C 5.203): and Basis of design flow(seats/ ons/sgft,etc.): Grease trap present(yes o):_ Industrial waste hold' tank present(yes or no):_ Non-sanitary waste scharged to the Title 5 system(yes or no): Water meter read" gs,if available: Last date of occ padcy/use: OTHER(d ribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):1L 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of alk components, to hj led(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 i Page 7 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: qC1& c5-t ,�t J t l t. Owner Q Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: cX34• Materials of construction:__cast iron —"PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: K (locate on site plait) Depth below grade: Material of construction:�c concrete metal_fiberglass ,polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: l S46 gic,,� Sludge depth:_ oZ a u Distance from top of sludge to bottom of outlet tee or baffle:30 Scum thickness: t u Distance from top of scum to top of outlet tee or baffle:�7 Distance from bottom of scum to bottom of outlet tee or affle: k N How were dimensions determined: _ M Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert evidence of leakage,etc.): l �l GREASE TRAP:_(Iocate on site plan) Depth below grade: Material of construction:`concrete me _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to of outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpin endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv evidence of leakage,etc.): 7 f Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t(� 4�t i1 V Owner: Wo.rxtv Date of Inspection: TIGHT or HOLDING TANK: (tank must umped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: ons/day Alarm-present(yes or no)- Alarm level: arm in working order(yes or no): Date of last pump Comments(con n of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:tam Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le a into or out of box,etc.): ,��/ p 6 OX 4At6 teltd fu tY'� ,po i. d��"C-4-11A PUMP CHAMBER: (locate on s' Ian) Pumps in working ory o): Alarms in working orr no): Comments(note conmp chamber,condition of pumps and appurtenances,etc.): g Page 9 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_W6 mak7m S �C t Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number._ _pC_leaching chambers,number leaching galleries,number. leaching trenches,number,Iength: 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.): 4(.-") 6�1 is OT r6y CESSPOOLS: (cesspool must be purr as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet:in�v . Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of constructi Indication of groul ater inflow(yes or no): Comments(note ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constructi Dimensions: Depth of solids: Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C,k a Owner: Date of Inspection: LO D 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 eaters the building- � r V` a� a� Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q41% v+ Owner: 0. Date of Inspection: 10 0(1 SITE EXAM Slope L;6!S Surface water_vtV Check cellar 1��b Shallow wells W'O Estimated depth to ground water—I.Affeet 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: -,,2[-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 y n established the high round w,�cfer Ievation: -r141 r p 4 ll e �f :vWNOFBAItNS'TABLE LOCA7ION ! S• i'YlK11n S�. SEWAGE # VILLAG ASSESSOR'S MAP & LOT�O 7 100� INSTALLER'S NAME&PHONE NO. V\AQnm h e r Som 1'k4 L. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �/ 'ReJ4,4gty'S (size) NO.OF BEDROOMS_/s _ BUILDER OR OWNER PERMIIDATE: "65:, �?�COMPLIANCE DATE: "�'�` � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r \\ �\ Ix $ 40. 00 No. 9 '�' Fee � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pphratiou for Mi5po5ar *pgtem Conotruction Vermit Application is hereby made for a Permit to Construct( )or Repair P)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.1—8 0 0—6 7 3—2 3 0 0 446 South Main Street CCB&T Hyannis ,Mass . 02601 Centerville,Mass . 02632 Installer's Name,Address,and Tel.No. 5 0 8-7 7 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8—77 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 Type of Building: Dwelling X No.of Bedrooms 4 Garbage Grinder NO) Other Type of Building No. of Persons Showers( )'-Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Loamy sand to medium sand Nature of Repairs or Alterations(Answer when applicable) O m i t t i n g c e s s p o o l s , Installing 1-1500 gallon tank 1—Distribution box and 4-330 rPehsraPr4 Date last inspected: 8/6.96 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by t 's and Health. Signed < d Date_8/6 96 Application Approved b Application Disapproved for the following reasons Permit No. �� Date Issued THE,COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALWDIVISION - BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced JKX)on by T.P.Msc+nmhar Pr Son jnn , for g&T Hyannis Offive as 446 South Main Street Centerville Mass. has been constructed in accordant with the provisions of Title 5 and the for Disposal System Construction Permit No. s� dated Use of this system is conditioned on compliance with the provisions set forth below: L 6 $ 40.00 i No. ,pl— Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �Biopogal bpgtem Construction Permit Permission is hereby granted to T.P Mn C..aMber X .0om Ixic to construct( )repairXXY)an On-site Sewage System located at Snlit"h Maain S+.rant—("enter-IrillIrM095� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: .•� Approved i No. G► " L+ Fee �+ .QQ k �- THE COMMONWEALTH OF MASSACHUSETTSf;. PUBLIC HEALTHIDIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mitpo.5al-6pgtem Con5truction 30ermit r� Application is hereby made for a Permit to Construct( ).or Repair�X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.1—8 Q 0—67 3—2 3 00 t 446 South Main Street CCB&T Hyannis,Mass . 02601 Centerville,Masg. 02632 Installer's Name,Address,and Tel.No. 5 0 8-77 5—3 3 3 8 Designer's Name,Address and Tel.No.5 0 8— 77 5—3 3 3 8 J.P.Macomber & Son Inc. - J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632 ; Type of Building: a Dwelling X No.of Bedrooms 4 Garbage Grinder G40) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. r, Plan Date Number of sheets Revision Date Title Description of Soil Loamy sand to medium sand Nature of Repairs or Alterations(Answer when applicable) 0 m i_t t i ng c e ss ss 0 01 g_ Installing j 1-1500 gallon tank 1--DiAribution box and 4-11� raaharmv rs Date last inspected: 8/h/9 h Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by is Board of Health01 Signed Date 8/6/9 6 i Application Approved b r �-•� Application Disapproved for the following reasons 4 Permit No. Date Issued -'" " }5_ :.)N OF SKCTCI-I AND APPLICATION FOR A DISPOaj��. ,i � �.tY i I;RitT�`;'y'7Tr''O�1T D'GSI�Nf+D nr r I,Joseph P. Macomber Jr. hereby certify that the application for disposal works construction permit signed by me dated 8/6/96 , concerning the property located at 446 South Main_Street Centerville,MA meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system 0 There are no private wells within 150 feet of the proposed septic system The observed groundwater table is .4 feet or greater below the bottom of the leaching facility • There is no increase in flow andlor pant c. in use proposed • There are no variances requested or needed. SIGNED : DATE: 8/6/96 LICEN ' SFTTIC SYSTEM INSTALLER IN 4THE TOWN OF BARNSTABLE NUMBER fr.frn 1, a ct�ptch rjj n of the oroposed sysicin. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,. i RECEIV=D Q�� Commonwealth of Massachusetts J U N 2 7 1996� HEALTH DCPT: Executive Office of Environmental Affairs WN HEALTH NST. ABLE Department of -M9V1SNM.40NMQ4 Environmental Protection 2c13aH1-N3H Willi am m F.Weld 966t L e N n r (aovemol Trudy Coxe S�cr�wy.EOEA Oavld ni Struhs Commiuloner SUBSURFACE SEWAGE DISPOSAL SYSTE4'11NSPECTION FORM MAP# PART Ate` PAR# CERTIFICATION Property Address:44lLi 5O\JL)r1 MA�o51'- Ce'14' (r\A' 0,10.1 Address of Owner: .Date of Inspection: 6-11 ylo (If different) ! ESSrJAS�AP'I�C Name of Inspector: M010) Rab rtsbn 3Qi PARVINO: Company Name, Address and Telephone WO�fnson Septic 43 Tomahawk Dr. CERTIFICATION STATEMENT Centerville I certify, that I have personally inspected the selvage disposaal lIster+Y?Mddress and that the information reported below is true, accurate and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems The system _ Passes _. Conditionally Passes Needs Further Ewaluauon B� the Local Apprut ing Authont\ Fans �/� Inspector's Signature:( le?&MvA Date: The System Inspector shall submit a copy of this inspec'yon report to the Approving Authority\within thirty (30) days of completing this Inspection If the system 1s a shared system or has a design flow ofi0,000 gpd or greater, the Inspector and the system owner shall submit the repor: to the appropriate regional office of the Dfhar,men! of Fn\nonmental Prowilon The original should tie seni !u !ne sw;ten, civ.ner anu cup r> x:.: ;u lilt JJ)U:, 11 ZIPP'-(.db�i tht, apt o,in •Y INSPECTION SUMMARY: Check A. B, C. or D A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. lrev:sed 8;:5/55I 1 One Writer Street a Boston,Massachusetts 02108 a FAX(617)556.1049 a Telephone (61 7)292-5500 w t.f Printed on Recleled Paper f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: �u��" �111A'1 Ce'1} tt1i� Cdta Owner: g;i�e' ES#� Date of Inspection: S-It-4(a B) SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven 'stribution box. The system will pass inspection if(with approval of the Board of Health): Z�j (s) are replaced n is removed n box is levelled or replaced The system requirean four times a year due to broken or obstructed pipe(s). The system will pass inspection if(withrd of Health): broken pipe(s) are replaced obstruction is removed CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Pael �S . Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD DF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN1'IR01.�tE1T: , _ imp wsteni nay a Septic tank anu bull duwrytiun bybrri'il anU i5 withir'-i 100 fcci to a surface v.'atEr SUpp!') 0; tri.bijtdrr l0 a surface water supply. _ The wstern ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and-is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• DJ SYSTEM FAILS: I have determined that the system violates o or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified bel . The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sew into facility or system component due to an overloaded or dogged SAS or cesspool. Dischar or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of cessp ol. (revised 6/25/95) 2 , 1 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 446 So,r�h m�� S+• Ce'�� rnA o��'3� Owner: 90,Ker E5?A 4e Date of Inspection: DJ SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last ye OT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, sspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is ithi,n 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or pri is within axone I of a public well, '' Any portion of a cesspool privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large,systems in addition to the criteria above: The design flow of syst/in200 pd or greater (large System) and the system is a significant,threat to public health and safety and the environment bmore of the following conditions exist: the system is of a surface drinking water supply the system ist of a tributary to a surface drinking %1(et-supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 446 SM'4h Cam• ►ilA• b.:X6,o. Owner: PAW Et,W4 Date of Inspection: rJ`�d_gb Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. I ` tl"As built plans have been obtained and examined. Note if they are not available with N/A. / . do. 01' V The facility or dwelling was inspected for signs of sewage back-up. JThe system does not receive non-sanitary or industrial waste flow j The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 4 The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. t J The iacihi) U�NI-r 10;'IJ UCCUuo:--',,, it ,,.cc provided ith information on the proper maintenance of Sub- Surface Disposal System. (revised 6/15/95) 4 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 446 5"h MA-n 5j• ce� Owner: BOW E5"i-e• Date of Inspection: 91014 FLOW CONDITIONS RESIDENTIAL: Design flow:"7W allons Number of bedrooms:, Number of current residents: 7. Garbage grinder (yes or no):fro S Laundry connected to system (yes or no):_.M Se?•P'`I Seasonal use (yes or no):_ND Water meter readings, if available: 1330 a ci S Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no_ Industrial Waste Holding T present: (yes or no)— Non-sanitary waste disc rged to the Title S system: (yes or no)_ Water meter reading if available: Last date of oc panty: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Town CC Bc�,rr+sfA�►e �tf System pumped as pan of inspection: (yes or no)_t�& If yes, volume pumnve gallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Ake'i. Sewage odors detected when arriving at the site: (yes or no) (revised 6/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 49io K14 061jx Owner: Ater Date of Inspection. SEPTIC TANK: V'Os1Q, pn S'{e (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to botto of outlet tee or baffle: Scum thickness: Distance from top of scum to t of outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Comments: (recommendation for umping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 0. GREASE TRAP: W04C 14-1 Ot (locate on site plan) Depth belov., grade. Material of construction: _concrete metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to 0o of outlet tee or baffle: Vista-ce fro^r hottoT ^' ' ^' 1" hnttnm pf oUi1o1. tee o, hahle Comments. (recommendation r pumping. condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural integrity, eviden of leakage, eu ) } (revised 8/15/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4�b So�r�s1 thA:n S� �ti o3.63a- Owner: Date of Inspection: TIGHT OR HOLDING TANK:MrtC (locate on site plan) Depth below grade: Material of construction: _concrete etal _FRP _other(explain) Dimensions: Capacity: gall s Design flo+v: lons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:YQnC (locate on site plan) Depth of liquid level a/oetert:Comments: (no;e a level and e. d ^c^ c' <o' ci•:cz ^.n.e . e�•idence of leakage into or out of box, etc) PUMP CHAMBER: W4s12 (locate on site plan) Pumps in working order:(yes no) Comments: (note condition of pu chamber, condition of pumps and appurtenances, etc.) (revised B/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: yyt SOv4h ► k^ S? Ce��' mA' 0)��3sk Owner: BAke�ES�R - Date of Inspection: ,S�It R6 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pit/nbe leaching ch :leaching galleaching treength: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: �X�`Nix Pco1b Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: fax Materials of construction: COnt• I,,K Indication of groundwater: NAB inflow (cesspool must be pumped as part of inspection) Ali Pftl- hRX AT i i� eR �llSaecz++a1 �J� � Qci� W3h SG Pee+ ec w +fmrtt�. •V � Comments: (note condition of soil, sign; of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of cons ction: Dimensions: Depth of solid Comments: ote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 6/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Sash rf wN ST coi, ca63). Owner: 6iw fi51�c Date of Inspection: Jr`lhQln SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' V�h �f1rf1 ST. 446 5Cu1'�t�1p:1 �t cw�f• ��1 S• 3 i C� 61, 6 le L (�q�A5z {��• Sy5{tm (s wcrk�� •Y Pocl h-15 poc) ++S is�..t4h4h^ 5` S pz Le-i(Arid • Q00` Lk DEPTH TO GROUNDWATER y% Depth to groundwater. l0{ feet __J method of determination or approximation: h�9'�r z� do lom heexc ao�a• (revised 6/15/95) 9