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HomeMy WebLinkAbout0520 SOUTH MAIN STREET - Health 520 South Main St.. A= �QECYCIEp� II No C^ H16_ ��, & HASTINGS.UN I J N . / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for D1pt108al fps Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.52 0 5,►M 4 i n 5-k Owner's Name,Address,and Tel.No.Wrq j,ryz�_ 6w 5 CQYN)re-V%X\Q. rAVw-.5. SLD S.1ri�in S� �er��rer�r��� bhV}b5 Assessor's Map/Parcel _0 Installer's Name,Address,and Tel.No. (FP—\c.S'`c 4p A)S Designer's Name,Address,and Tel.No. INl ei-47�h 5 �a�`1 I Vhz►-sl c�l+rli l\5 N11�,o Pd.60981 C S� w�ci., ►� . Type of Building: Dwelling No.of Bedrooms %3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building I eS ��_\ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 5a gpd Plan Date ��'�� Number of sheets Revision Date Title Size of Septic Tank / wd Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5�of the-Ejyx i tal Code and not t place the system in operation until a Certificate of ` Compliance has been issued by this Boar a th.- Sign Date I Z Application Approved by Date �— Application Disapproved by Date for the following reasons Permit No. _ �-�C) �— Date Issued C TOWN OF BAAMTABLE LOCATION 5Z6 . 6, Y (1) S SEWAGE# 2021 02 I VILLAGE &Y\)�WO��`�_ ASSESSOR'S'MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S60 LEACHING FACILITY:(type) 0i -cm\(size) NO.OF BEDROOMS OWNER r �� PERMIT DATE: 2- COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility)' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) : 1 Feet FURNISHED BY .14 ; Al 31 2Z' cS� 27 , s- �o be�-oLs y 00 Fee THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS , ZippIication for Bid'-posal bps In Construction 3permit 44 Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.5Z0 S,1A Zi, 5-�, O[^w,ner's Name,Address,and Tel.No\.Vj r9 i 6A Vf l-S Y3 Assessor's Map/Parcel 7..Q Installer's M6,Address,and Tel.No. CRi Designer's Name,Address,and Tel.No. �'k1 Cv t,_-Vt75 0b• ewx -11 Y►��rs�on�Y1a1\S h1ka. ��, �rx9�t rrSc� �cL, ►'s1 . Type of Building: Dwelling No.of Bedrooms �_, ` Lot Size sq.ft. Garbage Grinder( ) 1 Other Type of Building fGe°at�e� . _1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures 1 Design Flow(min.required) '330 gpd Design flow provided S gpd Plan Date Z I Number of sheets' Revision Date Title Size of Septic Tank /5-00 4* , Type of S.A.S. Description of Soil y Nature of Repairs or Alterations(Answer when applicable) \a CQt6oca iS tA -1- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not t >place the system in operation until a Certificate of Compliance has Been issued by this Board,,OL ealth. - Signed Application Approved by .___ Date G '� Application Disapproved by Date for the following reasons Permit No. / "<-' a' f Date Issued / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Coll pUance. THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(t/) Upgraded( ) Abandoned( )by r. 5�e.vV_hw_, C©►7!Aj-S 0+,.., T4 _ at hnc %V1 S _ C��-,fit trv�� has been constructed in accordance r� f with the provisions of Title 5 and the for Disposal System Construction Permit Ng04j- c)- I dated } / �- Installer EP I(_ STe'y.N C-, Designer YWL4 QV i SG 15 #bedrooms Approved design flow and The issuance of this permits all not be construed as a guarantee that the system will functionsigi�ed'-'as de Date Inspector , No.,qcz)-1 •''-•��i Fee / L/ THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal bpstr Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 52-0 1S. m6\n S�_ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. a Provided:-t struction must be,completed within three years of the date of this p� ermit. 1 � Date Approve�by „ Town of Barnstable Regulatory Services Richard V. Scali,Interim Director Public Health Division + Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Desismer Certification Form Date: . .�'\ Sewage Permit# w21 OZ I Assessor's Map\Parcel Cg 710 3 Designer: 1�4e,\jj6,y"',pInstaller: 42 i C. A5 Address: l ® Address: jC h An� oi-M. OZ0{ On 2 Z I was issued a permit to install a `" (Bate)-' ,l (installer) septic system at 5f!�0 ]w 1�W'll`J k. Ce", � ased on a design drawn by (address) j YY I/' dated 202.,l (dUthi"e er) I certify se tic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA a roval letters (if applicable) of. . nstaller �ignature 1140 �Pg (Designer's Signature) (Affix ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DI N. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc Zp No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatton for �Btoogal 46p.5tem Com5trurtton Vermtt Application for a Permit to Construct( )Repair(�O Upgrade(� Abandon( ) El Complete System Kindividual Components Location Address or Lot No. S oor14 Oti1AW r , Owner's Name,Address and Tel.No. Assessor's Map/Parcel CaJ-mut u-,or 3 Z Y/XRcLC�v�E-� t 2'7 03:3 Installer's Name,Address,and Tel.No. 5 QS YZ 1 4 877 Designer's Name,Address and Tel.No. ootbE l�Uvais� � . tJ 1A Type of Building: Dwelling No. of Bedrooms Lot Size %gjt5�sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow N gallons per day. Calculated daily flow NA- gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Cam!tj 9 Gka)C�F Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t ' oard of Health. Signed Date Cf 30 W;2.013 Application Approved by Date Zv t'f Application Disapproved fo e followin reasons Permit No.Z tI—-3 oy Date Issued 9/3 t?.v L- No.70 ' *.. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARN-STABLE., MASSACHUSETTS ZIpplication for Migo$at �bpgtem Cottgtructton Permit � -Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System (Individual Components Location Address or Lot No. 5'a,0 SocJTN (NA W >r T. ,Ow er's Name,Address and Tel.No. MATkS0'141E Woo�S Assessoi;s Map/Parcel , O 3 3 /r a13 Z N�M A 11J S-T SooTbA YAPuuou7r6( Installer's Name,Address,and Tel.No. 50$ q7)4877 Designer's Name,Address and Tel.No. CA06k)(vE GV7eAP696S "JCI N fA Is5-3 W 06(ac� c l*c. sr M4cff pem Type of Building: k Dwelling No.of Bedrooms " Lot Size 3�Pi 155 fsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( . ) Cafeteria( ) Other Fixtures A, w Design Flow A) gallonsper day. Calculated daily flow / W gallons. Plan Date Number of sheets Revision Date Title � f r Size of Septic Tank Type of S.A.S. Description of Soil y Nature of Repairs or Alterations(Answer when applicable) A i Date last inspected:.- " Agreement: .a 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 issued by t is"Board of Health. Signed �' A Date Application Approved by Date .7130 Zv I Application Disapproved for Ihe following reasons Permit No.Zo(1' 3 9,0 Date Issued ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( )by (WUW 1V E 6i�jT 1J656Y wC at �;1g SOV-04 kW tP ._,�'T` GL-7JT�12y/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No Za l3`30 o dated W WZ01 j Installer Ci4DQv . E Q6 WC Designer A n The issuance of guarantee s t h not be construed as a that the s to / 1`un1i,7o)taAd/esignqDate Inspector No.G._�(�! 77�a --------------------------Fee t 00ra THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ;Di2;po.5a1 *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(x )Upgrade( )Abandon( ) System located at JtaO 500710 M,*ItU St CeeVZdq_V t ,C.�% and as described in the above Application for Disposal System Construction Permit. The applicant re c n" es his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi ermi Date:_,_cam _ Approved by Commonwealth of Massachusetts ILI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information �autnnrrru� filling out forms � INA OF ,9 Y,,� on the computer, �• ..........sS,ycG,�� use only the tab 1. Inspector: key to move your moo? '•yG JAMES cursor-do not James D.Sears use 9W SEARS key the return Name of Inspector #; Ca ewideEnterprises,LLC �, °F T►F��y's ?� ®I[=11 Company Name N SP�G 153 Commercial St. Company Address ,ate Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S1623 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. 1 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 9-17-13 C46spector'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. � d 104/1 � tsins•31 3 Title 5 Offiaai Inspection F rfece Sewage Dis posal System•Page t of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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: Front System Laundry and Kitchen on front system. 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): t5irrs-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St-(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityfrown 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 Forth:Subsurface Seaga Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 520 So. Main St.(Front System) Property Address Margorie Woods Owner owners Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 Tare 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 Al ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in is less than 6"below invert or available volume is less than.%day flow ✓ l7- Lt*513 Title 5 Orfidal Inspedlon Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 520 So. Main St.(Front System) Property Address Margone Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner owner's Name information is required for every Centerville MA 02632 9-16-13 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? A ❑ ❑ 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 thec manholes uncovered, opened, and the interior inspected for the condition of the W111111111111W 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Citylrown State Zip Code Date of Inspection D. System Information Description: One C. Pool and Pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-78,000Gals 9 ( Y 9 (gP )) 2012-0 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Offidal Inspection form:Subsurtace Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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: ® ,soil absorption system ® 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 Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts ID 07 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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: NA Were sewage odors detected when arriving at thesite? El Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Pipeing is Cast iron, clay and PVC. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 T8le 5 Official Inspection Form.Subsudece Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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.): Leaching is a 4' Precast pit w/2'stone. Pit at 1'Below grade. Pit is clean and dry. Wall's clean w/stain line at 6". No sign of over loading or solid cant'over. Al Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry Dimensions of cesspool 7' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments pY 520 So. Main St.(Front System) Property Address Margorie Woods Owner owner's Name information is Centerville MA 02632 9-16-13 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool 7'block w/steel cover at grade. Pool is dry. Two lines in w/no tee's, outlet PVC Tee. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town 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 t5ins•3/13 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 ............... 0 ...........<2 A.......... .................. .......... .............. ............. .......... .......... ............ ............... .......... .............. .......... ........... . ......... ...... .... ............ .............. ............ ............ ............ ... ........... ............. ........... ......... .......... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N® 20+' Estimated depth tough ground water. let 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: Area and lot high from Rd.and abutting property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official hspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 520 So. Main St.(Front System) Property Address Margorie Woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityfrown 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•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 :}ct 01 13 08:39p � ,� gyp,, � ti■ � he��s17 Commonwealth of Massachusetts ■ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property address - MaMorie woods Owner Owner's Name infomration is required for every Centerville MA 02632 10-1-13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:outf rms A. General Information filling out forms ```�utuuuilHhgr on the computer, \�.�``��,SH OF Mq`SS%•,�� use only the tab 1. Inspector: �•��`��' .��'y key to move your cursor-do not _ P =i�? .JAM ES use the return James D. Sears _ key_ Name of Inspector ; �`�� CapewideEnterprises,LLC r•. 0.•0. a/(I , I I Company Name N SP �o`v— — 153 Commercial St. r�irrrlrllll��tit11U����` Company Address ^� Mashpee MA 02649 Cdyfrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 certif y 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 1&340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-1-13 02pector'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. 113 Title 5 011icial Inspec0on Forth:Subsurface Sewage Dispose!System•Pepa 1 0117 Mns-3 �� ®p/ Oct 01 13 08:39p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owners Name information is Centerville required for every MA 02632 10-1-13 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Rear System Note: Laundry and kitchen go's to Front System 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 exffltration 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): tsins•3113 Title 5 Official Inspection Form;Subsurface Sewep Disposal Syslem•Page 2 of 17 Oct 01 13 08:40p p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owners Name information isequirred for every very Centerville MA 02632 10-1-13 page. City/Town State Zip Code Date or inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpsialarms are repaired. B) System Conditionally Passes (coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(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 Ojos 3H3 Title S Ofridd Mspemon Forrtc Subuaface Sewage Dispcsel SysDem•Page 3 or t l Oct 01 13 08:40p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 520 So-Main St. Rear System Property Address Margorie woods Owner Owner's Name Information is required for every Centerville MA 02632 10-1-13 page. cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 pil 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 AIA ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in Esaspoel is less than 6"below invert or available volume is less than' day flow P.TT' Mina•W13 Title 5 Mad kmpacbm Form:Subwxfeoa Sewage Disposai System•Page 4 of 17 Oct 01 13 08:40p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page- CitytTown 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 11 of a public water supply well If you have answered"yes"t6 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. 65ia-3f13 Title 5 gulf ial I respealon Farm:Sutxwrraca Swage DL4posa4 System-Page 5 of 17 Oct 01 13 08:40p p g Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Cityfrown 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 ? Y d the SAS located on site?Ao g , ® ❑ Were theme manholes uncovered, opened,and the interior MWQQW inspected for the condition of the .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: AIA ❑ C] Existing information. For example, a plan at the Board of Health- ET ® 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form Subsurface SeWage Disposal System-Page 6 of 17 Oct 01 13 08:41 p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address - Margorie woods Owner Owner's Name informatrequired is Centerville DNA 02632 10-1-13 required for every page. City/town State Zip Code Date of Inspection D. System Information Description: The system is a C Pool and Pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2011-78,000Gais 9 Y 9 (gP ))= 2012-0 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NADate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/personslsq.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: Mm•3113 Title 5 Official knpection Forth Submwfeoe Sewage Disposal System•Pepe 7 of 17 Oct 01 13 08:41 p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name required fo is ry Centerville required for eve MA 02632 10-1-13 page. city/Town State Zip Code Date of Inspection D. System Information (cost_) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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: ® , soil absorption system ® to cesspool ❑ Overflow cesspool ❑ Privy. ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativelAltemative 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): 15ins•3R3 Title SOfRpel tnarxdion Fomr.Subsurface Sewage plsposal System•Page B of 17 i Oct 01 13 08:41 p p.g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address M_argorie woods Owner Owner's Name requir required is Centerville MA 02632 10-1-13 required for every page. Citylrown state ZIp Code Date or Inspection D. System information (cont.) Approximate age of all components, date installed(if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: %,t Comments(on condition of joints, venting,evidence of leakage, etc.): Pipeing is 4"cast iron and PVC SCH 40. Note: PVC Lines are new. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/73 Title 5 Official Inspedion Fonrr Subsurfew Sewspe Disposal System-Page 9 of 17 Oct 01 13 08:42p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1W 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ku-W3 Title 5 Official Irmpeaion Form:Subasfarq Sewage Disposal System-Page 10 or 17 .Oct 01 13 08:42p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owners Name information is Centerville MA 02632 10-1-13 required for every . page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3113 Title 5 Official hapeclion Form:SuDsurlace Sewage Disposal System.Page 11 of 17 Oct 01 13 08:42p p,12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St Rear System Property Address Margorie woods Owner Owners Name information is nequ"fired for every Centerville MA 02632 10-1-13 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5imB 3/13 TiBe 6 plridal Inspeeian Form:Subsudaae Sewege Disposal System•Pape 12 or 17 Oct 01 13 08:43p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 page. Cityrrown State Zip Code ©ate of Inspection Q. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal_ precast pit w/2' stone. Pit and cover at 201' below grade,dry . Wall's clean, like new. No sign of overloading or solid carry over. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): / 1 Number and configuration Depth—top of liquid to inlet invert Dry Depth of solids layer Dty Depth of scum layer Dry Dimensions of cesspool 5' Materials of construction Block Indication of groundwater inflow ❑ Yes 1Z No tNns•W13 Title 5 Of ial Inspection Form:SubsuAaoe Sewage Disposal System•Pape 13 of 17 Oct 01 13 08:43p p.14 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St Rear System Property Address Margorie woods Owner Owners Name informationis every Centervifie required for eve MA 02632 10-1-13 page. Cityrrown State Zip Code Date or Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Main pool 5' Deep block w/cover at 6". Pool is dry. One line out wl PVC tee Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 15ins-N13 Title 5 Official In3pec0on Form;Subsurface Sewage Disposal System•Page 14 0177 Oct 01 13 08:43p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margone woods _ Owner Owner's Name information is required for every Centerville MA 02632 10-1-13 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 tslns•3R3 Title 5 Official kupec Om Fortes Scbsurrace Sewage Diapaaal System•Pape 15 of 17 e 0 � o . o w ,3 Ycv f/ j4 P is _ , .Oct 01 13 08:44p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So Main St Rear System Property Address Margode woods Owner Owners Name requirefo � Centerville MA 02632 10-1-13 required for every page. cityrro" State Zip Code Date of Inspection D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20-V 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: ❑ Ghecked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Area and lot high from Rd. and Abutting Property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Tale 5 ORdel Pespection Form:Subwftce Sewage Disposal System•Page 16 of 17 Oct 01 13 08:44p p.18 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-foot for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owners Name information is required for every Centerville MA 02632 10-1-13 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-3A3 TiUe 5 OlrWal knpedim Form Subudeoe Sewage Di sposel Syrem•Page 17 0117 j 1 i "C..- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St'Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. el Important:when filling out fortes A. General Information on the computer, ��``�``�ZN OF use only the tab 1. Inspector: .``� ��•••"..... key to move your / B ��•• .Oy cursor-do not , use the return James D. Sears ;s: JAMES :�' c key. Name of inspector =0: SEARS CapewideEnterprises,LLC = _ Company Name 153 Commercial St. 'o�F s I SPFG Company Address 111tiflIVOW. Mashpee MA 02649 City/Town State Zip Code 508477-8877 S1623 Telephone Number License Number y B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-17-13 &IRspector'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, thl 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. (0 / v/ a 3 t5ins•3/13 Title 5 Offidal Ins pection Forth:S Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ® 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): Orange Burge Pipe roots and brakes in line. Need to replace line's house to main pool. ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown 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: Rear System Note: Laundry and kitchen go's to Front System. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �f 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityfrown state Zip Code Date of Inspection B. Certification (cunt.) 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 is less than 6"below invert or available volume is less than%day flow Pi7- t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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 11 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. Oins-3113 Title 5 Official tnspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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 SEMOMM manholes uncovered, opened, and the interior inspected for the condition of theAMUMM 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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown state Zip Code Date of Inspedion D. System Information Description: The system is a C Pool and Pit. 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011-78,000Gais 2012-0 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NADate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 rdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 SoWain St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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: ® 4 soil absorption system ® JSW 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 Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Mar orie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Cast iron and orange burge. Roots and brakes in line's. Need to replace line's, house to main pool. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official inspection Fond: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 J"e 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityfrown 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): f 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 520 So.Main St. Rear System Property Address Margorie woods Owner owner's Name information is required for every Centerville MA 02632 9-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owners Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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.): Leaching is a 1000 Gal. precast pit w/2'stone. Pit and cover at 20"below grade,dry .. Wall's clean, like new. No sign of overloading or solid carry over. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Dry Depth of solids layer Dry Depth of scum layer Dry Dimensions of cesspool 5' Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 T Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Main pool 5' Deep block w/cover at 6". Pool is dry. One line out w/PVC tee. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 1 : I , t : O ' ... .. , I 1 I , 4 A I : f s 4 I i , i 1 .. I i 1 I t ! ( 1 4 ., i 1 i , Y.. i I , , , + ..: ..:.�: �.... I , f t f 1 1 , I , I 1 ' r : 1 f , 1 + � 1 , 1 ! •a..I + / 1 1 3 : - 1 I. ,.; .....1 ..' .•........,. ; I i ( i t i I 1 i ' i i 1 , ... i , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No feet Estimated depth t�igh ground water. 2 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: Area and lot high from Rd. and Abutting Property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 official Inspectlon Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 520 So.Main St. Rear System Property Address Margorie woods Owner Owner's Name information is required for every Centerville MA 02632 9-16-13 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 Disposal Sewage pose System•Page 17 of 17 Bottle Number: 01204 Date: 02/01/99 Barnstable County Health and Environmental Laboratory Superior Court House, Route 6A P.O. Box 427 Barnstable, MA 02630 Client: WOODS, J.D. Collector: H.L. WOODS Mailing P 0 BOX 355 Affiliation: OWNER Address: CENTERVILLE, MA 02632 Type of Supply: W Telephone: f-771-00' -36- Well Depth: Sample Location 520 SO MAIN ST Date of Collection: 01/22/99 Town: CENTERVILLE !>'/! Date of Analysis: 01/22/99 PARAMETER SAMPLE RESULT RECOMMENDED LIMITS ------------- Total Coliform Bacteria/100mL ABSENT 0 Conductivity (micromhos/cm) 255 500 Iron (ppm) < 0. 1 0. 3 Nitrate-Nitrogen (ppm) 6.2 10. 0 Sodium (ppm) 30 20. 0 Copper (ppm) 0.3 1. 3 BASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN: * Water sample has higher than average levels of nitrates. Future monitoring is recommended (2-3 times per year) to establish any upward trends. * Based on the results of the parameters tested, the water is suitable for drinking but has high levels of sodium. Persons on a low sodium diet should consult their doctor. 21 Thomas F. Bourne, Laboratory Director CEN TER VI LLE PROPOSED CONTOUR ' � ® PROPOSED SPOT GRADE EXISTING CONTOUR BUMPS RIVER RD ` + 96.52 EXISTING SPOT GRADE v� W— EXISTING WATER SERVICE TEST PIT LOCUS SCALE: 1"=50' p 520 so. MAIN sT. it �� ■� '� CD S I \ SO. \ LOCUS MAP `�i ♦ TBM a EL.34.5 . BULKHEAD FOUNDATION ` r 3� LOCUS INFORMATION TITLE REF: 28070/006 PARCEL ID: MAP 187 PAR. 033 FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE SEPTIC SYSTEM �'���'\ REPAIR PLAN 1 ��';�Y�►`\ ® i1 LOCATED AT: 520 SOUTH MAIN STREET CENTERVILLE, MA PREPARED FOR VI R G I N I A G A VR I S, TR S T. —_— \p JANUARY 7, 2020 EDGE OF WETLAND OF DARKEN, \Not -- ------ �1 a� '9 MEYER & SONS, INC. P.O. BOX 981 EAST SANDWICH, MA. 02537 PH: (508)360-3311 FAX: (774)413-9468 meyerandsonstitle5©gmail.com SHEET 1 OF 3 CENTERVILLE \ - PROPOSED CONTOUR \ TBM = EL. 34.5 ® PROPOSED SPOT GRADL \ BUMPS RIVER RD-- 98 -- EXISTING CONTOUR y � BULKHEAD FOUNDATION + 96.52 EXISTING SPOT GRADE N W EXISTING WATER SERVICE �� TEST PIT LOCS SCALE: 1"=20' p 520 SOO. MAIIN ST. CD \ LOCUS MAP 4 LOCUS INFORMATION TITLE REF: 28070/006 PARCEL ID: MAP 187 PAR. 033 FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE -\� \ ',� 1 ► \ \ \ \ 2\ 2� SEPTIC SYSTEM 38s� \\ I 5 ft. solL REMOVAL REPAIR PLAN LOCATED AT: 520 SOUTH MAIN STREET 40 ml POLY LINER (note 105) CENTERVILLE, MA PREPARED FOR ,� \ �• I / VIRGINIA GAVRIS, TRST JANUARY 7, 2020 OF DAMYE M ` 0. 1 \ \ \ \ 0 / MEYER & SONS, INC. `\ \\\ PROP. 1 ,50OG POLY — P.O. BOX 981 \ SEPTIC TANK / i A EAST SANDWICH, MA. 02537 PH: (508)360-3311 FAX: (774)413-9468 \ / , meyerandsonstitle5C�Dgmail.com SHEET 2 OF 3 NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS NOTE: TO PREVENT BREAKOUT, THE PROPOSED GENERAL NOTES: TOF SEPTIC TANK FINISH GRADE SHALL NOT BE < EL:25.00 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL EL.=34.50f INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX FOR A DISTANCE OF 15' AROUND THE 89ARD OF HEALTH AND THE DESIGN ENGINEER. OUTLET AND SET TO 6" OF FINISH GRADE PERIMETER OF THE SA.S. 2. ALL WORK AND MATERW.S SHALL CONFORM TO THE REQUIREMENTS INSTALL RISER & COVER PROPOSED SSA.S. OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE INSTALL LOCKING COVERS IF AT FINISH GRADE SET TO 6" OF GRADE INSTALL A 4" DIAMETER INSPECTION PORT OVER LOCAL RULES AND REGULATIONS. F.G. EL.=32.0$ F.G. EL.=30.0f F.G. EL: 28.0t ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE 13ACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE F.G. EL: 28.0(MAX.) DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 9" MIN COVER/ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 36 MAX COVER L - 25' L - 15(MAX) ENGINEER BEFORE CONSTRUCTION CONTINUES. O S=1% (MIN.) EL-27.50 O Ss1% (MIN.) O S=1% (MIN.) INSTALL TWO INSPECTION PORTS (MIN.) 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC • 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10• 6 THE FOR PROPER INSPECTIER ONS S DURNG THE CONSTRUCTION. OF �+ INV.=26.50 14 11.3" TO 7. DWEWNG IS SERVICED BY TOWN WATER. 4e"uouro INV.=26.25 INVERT LEVJ<L INV.=24.61 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED PROPOSED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. GAS BAFFLE D-BOX INV.=25.80 4 ROWS OF 6 UNITS AT 6.25'/UNIT 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE INV.=26.0 DB-6 LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING WORK. SOIL ABSORPTION SYSTEM (PROFILE) 10. DOTING CESSPOOLS To BE PUMPED, CRUSHED AND FILLED ' PROPOSED POLYL 1.500 GALLON SEPTIC TANK PER TITLE 5. REPLACE WITH CLEAN MEDIUM SAND. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION EXIST. SEWER OUTLET RESTORE VEGETATIVE COVER 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY INV.=32.32� AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY B INV.=32.00 BACKFlLL WITH (MEAN PERC SAND TO TOP OF CHAMBERS 13. NO KNOWN ABUTTING PRIVATE WELLS WITHIN 150 FT. OF PROPOSED. LEACHING �•, l., PLACE FILTER FABRIC 14. ALL PIPING TO BE 4" SCH 40 O 1/8-/FT (UNLESS SPEC. ) r ;.. OVER TOP OF CHAMBERS i;', ;-:• 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTINGBREAKOUT=TOP ELEV.=25.00 FOR THE USE OF A GARBAGE GRINDER. PIPE INVERTS PRIOR TO CONSTRUCTION INV. ELEV.= 24.61 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 2) TANK/D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.= 23.67 t. EXISTING SUITABLE 17. REMOVE UNSUITABLE SOILS 5 FT AROUND LEACHING TO EL 23.18 OR GRADE ON A MECHANICALLY COMPACTED SIX 2,83' MATERIAL TOP OF 'C" LAYER AND REPLACE W/ CLEAN MED. SAND PER TITLE 5 INCH CRUSHED STONE BASE, AS SPECIFIED IN 51 MIN. ABOVE BOTTOM OF 18. PLACE A 40 ml POLY LINER AT EDGE OF 5 FOOT SOIL REMOVAL 310 CMR 15.221(2) T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' 11.32' AS SHOWN FROM EL. 25.0 - 21.0 TO PREVENT BREAKOUT (7.67' PROVIDED) USE 4 ROWS OF 6-HIGH CAPACITY 3) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE: EL 16.0 DESIGN CRITERIA GAS BAFFLE AS REQUIRED = INFILTRATOR (H20) UNITS SEPTIC SYSTEM PROFILE NUMBER OF BEDROOMS: 3 BEDROOM DWEULNG N.T.S. DESIGN FLOW: RESIDENTIAL: 3 BEDROOMS O 110 GPD/BR = 330 GPD DESIGN PERCOLATION RATE: <2 MIN/IN SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) SOIL LOGS GARBAGE GRINDER: NO (not designed for garbage grinder) DISTRIBUTION BOX: USE DB-5 (1-120) DATE: DECEMBER 14, 2020 OF SEPTIC TANK: 330 gpd x 200% = 660 gpd USE PROP. POLY 1,500E SEPTIC TANK SOIL EVALUATOR: DARREN M. MEYER, RS, CSE 1614 �� s9 LEACHING AREA REQUIRED: (330)/.74 = 445.94 S.F. WITNESS: DAVE STANTON, BARNSTABLE HEALTH DARREN M. YE PRIMARY S.A.S. NO. 11 O USE 4 ROWS OF 6 - HI-.CAP INFILTRATOR 0-20 UNITS-NO STONE Eaev. TP-1 Depth Elev. TP-2 Depth / M\..._ 28.20 A 0" 26.0 0" 'R`G�SfE BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF CHAMBER) LOAMY SAND LOAMY LOAMY SAND (CHAMBER)(CHAMBER) 24 UNITS x 6.25 LF x 4.73 SF/LF 709.5 SF IOYR 3/2 1OYR 3/2 26.78 B 17" 24.75 15" TOTAL AREA 709 B LOAMY SAND LOAMY SAND ( = .5 SF 25.20 1OYR 5/6 36" 23.18 IOYR 5/6 34" I DESIGN FLOW PROVIDED: 0.74GPD/SF(709.5 SF) = 525 GPD > 330 GPD req'd PERK TEST C1 C1 FOOTPRINT: 37.5 X 11.32 = 424.5 SF > MADEP REQUIRED 400 SF. OEL 23.53 MEDIUM MEDIUM SAND SAND 2.5Y 7/4 2.5Y 7/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 18.20 J 120" 16.0 120" 520 SOUTH MAIN STREET, CENTERVILLE, MA PERC RATE <2 MIN/IN. ("Bwb" HORIZON) Prepared for: Virginia Gavris System Design and Topography Plan by: SCALE DRAWN DATE MEYER&SONS,INC. N.T.S. DMM 01/07/21 PO BOX 98f REV DATE CHECKED SHEET NO. EAST SANDWICH,MA 02537 508-362--2922 DMM 3 of 3