HomeMy WebLinkAbout0630 SOUTH MAIN STREET - Health 630 South Main Sty
Centerville %
A= 186 - 042
UPC 12534 o-
No.2-153LOR SteOWO�30
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c Commonwealth of Massachusetts l��p� o7d—
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
V�
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville ✓ MA 02632 8/13/2020
page. Citylrown 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 filling out forms A. Inspector Information S( TV a,(o
on the computer,
use only the tab James Ford
key to move your Name of Inspector
cursor-do not Ford Septic Services, LLC
use the return Company Name
key.
P.O. Box 49
� Company Address
Osterville MA 02655
City/Town State Zip Code
,ten 508-862-9400 S 12482
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. Fails
8/15/2020
Inspect r Signature Date
The sy m inspecto shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
iv Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
V�
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
u�
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
The system has a septic tank and soil absorption system SAS and the SAS is within
❑ Y p P Y (SAS)
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a.surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c !% 630 South Main Street
V
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
El ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: weekend useDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
� nsp
''- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.�� / 630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
cM !% 630 South Main Street
u
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
3/5/1986 per as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
n Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.�� 630 South Main Street
u�
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
101,
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: 1000
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle 21
Scum thickness 2
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 15
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The Tee's were present. There was no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
V'
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass . ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
I
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
cam !% 630 South Main Street
V
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
N/a
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Even
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.):
The D-box was normal and no solids were present. The cover was at 6"
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
u
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3- Flowdiffussers20'x16'
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
!?, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
V
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is
required for every Centerville MA 02632 8/13/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was dry and clean. There was no sign of failure. A camera was used. The bottom to grade
was 3.0'
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
n/a
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
- c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`.c� 630 South Main Street
u
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/a
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
• • Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 0 630 South Main Street
u—
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A Q
a �
3 O O
�{ o
A
a is 3a
3 /y 4' 38
6 C
y ag y3
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
,A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.;, 630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 5.4+/
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from
system design plans on record
Y 9
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:
Topo and water contours mapd
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I hand augered down to groundwater which was 6.5' below grade. The high groundwater adjustment
for this site was MIW 29 July 2020 was 1.1'. Making the adjusted groundwater level 5.4'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c // 630 South Main Street
Property Address
Carl & Debra Sylvester
Owner Owner's Name
information is required for every Centerville MA 02632 8/13/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Jun 26 2016 23:21 Jim The Inspector Man 5085349919 page 18 Rd "At 35�77
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
630 South Main Street
Property Address
Carolyn Sheldrick _
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
page. CityfTown State Zip Code Date of Inspection
i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
Q 1� ] � �aut11i1u+Npp
on the computer, �tK
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use only the tab 1. Inspector: : �iz
key to move your o.• G
cursor-do not James D.Sears JAMES :rt1
use the return Name of Inspector
key.
T Capewide Enterprises, LLC �'.• o_
Company Name r6 •`
r1L 153 Commercial Street ��� , I �p §0`
Company Address
Mashpee . MA 02649
City/Town State Zip Code !:
508-477-8877 S1623
Telephone Number License Number i
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000). The system:
i
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-23-16
pector's Signature Date 4(Boardl,
The system inspector shall submit a copy of this inspection report to the Approving Authority
of Health or DEP)within 30 days of completing this inspection. If the system.has a design flow of `
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the r
buyer, if applicable,and the approving authority.
"*"This report only describes conditions at the time of inspection and under the conditions of use `
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 1 of 17
i
Jun 26 2016 23:22 Jim The Inspector Man 5085349919 page 19
Commonwealth of Massachusetts
L
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-1.6
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 n
A) System Passes:
ES
® 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:
The system is a 1000 Gal Tank D Box and three chambers.
i
r
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):
� I
Y
Y I
t6ins.doc•rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pape 2 of 17
1
Jun 26 2016 23:22 Jim The Inspector Man 5085349919 page 20 r
{
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Carolyn Sheld(ck
e
Owner Owner's Name
information is C MA 02632 6-23-16
Centerville r
required for every State Zip Code Date of Inspection
page. Cityrrown
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 th'e 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):
4
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
i-
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): _
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
r
E
❑ The system required pumping more than*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):
i<
' r
C3
E `
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:
I' ❑ 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
tSins.doc-fev.E116 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
s
Jun 26 2016 23:23 Jim The Inspector Man 5085349919 page 21
r
Commonwealth of Massachusetts
_ Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k
e
630 South Main Street
Property Address
Carolyn Sheldrick =
Owner Owner's Name
information is Centerville MA 02632 6-23-16
required for every State Zip Code Date of Inspection
page City/Town
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
e
❑ 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. E
❑ 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 x
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 F
be attached to this form.
3. Other:
i
C '
( 1
i
r
• I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections: j
Yes No
El ® 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
F.
El ® Liquid depth in is less than 6"below invert or available volume is less
than Y2 day flow /f/N G-
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 at 17
i
Jun 26 2016 23:23 Jim The Inspector Man 5085349919 page 22
i;
F`
(i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
630 South Main Street
Property address
Carolyn Sheldrick
Owner Owner's Name
information is MA 02632 6-23-16
required for every Centerville
State Zip Code Date of Inspection
page. Cityfrown
B. Certification (cont.)
Yes No € i
Required pumping more than 4 times in the last year NOT due to clogged or `
❑ ® obstructed pipe(s). Number of times pumped:
❑ ElAny portion of the SAS,cesspool or privy is below high ground water elevation.
- i
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or r
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 E
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.]
l:
❑ ® 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 t
criteria exist as described in 310 CMR 15.303, therefore the system fails. The r
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. P
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. r
f .
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 F
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,
l5ina.doc•rev.6116 . Title 6 Official Inspection Form:Subsurface Sewage Disposal System•page 5 of 17
' i'
Jun 26 2016 2324 Jim The Inspector Man 5085349919 page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 630 South Main Street
Property Address
Carolyn Sheldrick
kt
Owner Owner's Name
information is Centerville MA 02632 6-23-16
required for every State Zip Code Date of Inspection
page. Cityrrown
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following: i
Yes No I
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
td
❑ ® 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
-
® ❑ Was the site inspected for signs of break out? r
❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
Inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum? I
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)1310 CMR 15.302(5)]
D. System Information
z
Residential Flow Conditions:
�-
Number of bedrooms(design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330
t6ins.doc.rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-pop 6 of 17
r.
Jun 26 2016 2325 Jim The Inspector Man 5085349919 page 24
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
i
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
page. City/Town State Zip Code Date of Inspection
D. System Information
{
Description:
The system is a 1000 Gal Tank D Box and three flows.
i
,
E
0
Number of current residents:
Doed residence have a garbage grinder? ❑ Yes ® No r
i
i
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 i
t.
2014-46,000Gais .
Water meter readings, if available (last 2 years usage (gpd)): 2015-3,000 Gal's
Detail:
i'
i
1<
Sump pump? ❑ Yes ® No
NA
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
C
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
F
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No R
• 3
Water meter readings, if available:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage 019pose1 System•Page 7 0117
Jun 26 2016 23:25 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
page. City[Town State Zip Code Date of Inspection
D. System Information (cont,)
Last date of occupancy/use: Date F
Other(describe below):
r
General Information
r °
Pumping Records:
Source of information: NA
L
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
w
❑ Single cesspool
t
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) i.
❑ 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.
i ❑ Other(describe):
t5ins.doc•rev.6/16 - Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
e.
4
Jun 26 2016 23:25 Jim The Inspector Man 5085349919 page 26 `
i.
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Fri
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16 '
z,
page. Cityffown State Zip Code Date of Inspection
D. System Information (cost.)
r
Approximate age of all components, date installed (if known) and source of information:
1986 Permit#86- 1151 New D Box 5-14.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): "
20" s
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.):
Pipeing is 4" PVC SCH 40.
r
Septic Tank (locate on site plan):
10"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
;
r
t
If tank is metal, list age: years '
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 4
Dimensions:
1000 Gal. Precast
.
1"
Sludge depth:
t5ins.doc•rev.6M 6 - Title 5 Official Inspection Form:Subsdrfaca Sewage Disposal System•Pape 9 of 17 i`
f
Jun 26 2016 2326 Jim The Inspector Man 5085349919 page 27
• r
I.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Properly Address e
Carolyn Sheldrick
Owner Owner's Name
information is MA 02632 6-23-16
required for every Centerville
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
r
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 29
o,.
Scum thickness
Distance from top of scum to top of outlet tee or baffle 12 is
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Abuilt-Tape-Plan
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level, Tank and covers at 10"below grade. Inlet tee, outlet baffle. No sign of
leakage or over loading
C
i`.
'r
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): r
Dimensions: F
C
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
e
Date of last pumping: Date
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposa System-Page 10 of 17
f- ,
Jun 26 2016 23:26 Jim The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is
required for every Centerville MA 02632 6-23-16
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.) j
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.): r
a
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Y
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.): -
i
f
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
i -
t5ins.dOC•rev.8/16 Title 5 Official Inspection Form:Subsurface Sewage nisposal System-Page 11 of 17
Jun 26 2016 23:26 Jim The Inspector Man 5085349919 page 29
T✓
' I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
t;
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-14" below grade w/one line out. Cover at 6" below grade. Box is new 5-14.
` j
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.):
r
rt ,
If pumps or alarms are not in working order, system is a conditional pass.
s
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
s.
t5ina.doc-rev.6116 Title 5 Official Inspectlon Form:Subsurfane Sewage Disposal System•Page 12 of 17
Jun 26 2016 23:26 Jim The Inspector Man 5085349919 page 30
:K
i`
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
E
630 South Main Street
Property Address
Carolyn Sheldrick r
Owner Owner's Name K
information is Centerville MA 02632 6-23-16 `
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type: [:
❑ leaching pits number.
® leaching chambers number: 3
s
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
P=
Type/name of technology:
h
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
-Leaching is three flows w/4'stone. Flows are 19" below grade. Clean and dry. i.
4
i.
r=
Y
f.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert G
t
Depth of solids layer
4,
Depth of scum layer
Dimensions of cesspool f
i<
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
i
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
4
Jun 26 2016 23:26 Jim The Inspector Man 5085349919 page 31
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form_-Not for Voluntary Assessments
630 South Main Street
Property Address
Carolyn Stieldrick
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.) r
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
� 1
i
L.
I
Privy (locate on site plan):
Materials of construction:
C
Dimensions
Depth of solids
a
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, r
etc.): f
f�
Ir
s.
a
t5ins.doc•rev.W115 Title 5 Official Inapsoon Form:Subsurface Sewage Disposal System•Page 14 of 17 t
t
i_
=i
Jun 26 2016 2327 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts r
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address i.
Carolyn Sheldrick a;
Owner Owner's Name
information is required for every Centerville MA 02632 6-23-16
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 s
s
t
7 - - 3 v2
19-3 1 y-I G
-3
�h m
s
r
't
Y
F
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
'r
Jun 26 2016 23:27 Jim The Inspector Man 5085349919 page 33
• Y
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
630 South Main Street
1 :
Property Address
Carolyn Sheldrick -
Owner Owner's Name
information is MA 02632 6-23-16
required for every Centerville
page. City/Town State Zip Code Date of Inspection r
D. System Information (cont.)
Site Exam:
❑ Check Slope r i
❑ Surface water
� i
❑ Check cellar w 1,
s
❑ Shallow wells
Estimated depth to high ground water: feet 6
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 {
is
® 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:
r ;
You must describe how you established the high ground water elevation:
Hand Auger T.H. 6 6"water. Bottom of flows at 3' below grade. Bottom of flows at 3'6" above
TH.
w :
e E
p
ft
F
rt
r:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
isins.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f
Jun 26 2016 23:28 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Carolyn Sheldrick
Owner Owner's Name
information is
required for every Centerville MA 02632 6-23-16
Page, Cityrrown State Zip Code Date of Inspection
F
E. Report Completeness Checklist
{
® Inspection Summary: A, B, C, D, or E checked
Y '
® 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
i
s
c
4
2•
a
t
' f
Y '
F
L
6i a
L
S
15ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
t _
gay 21 1410:50a p.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt " V-t,y7y�, ea,
Owner Owner's Name
information is required for every Centerville MA 02632 5-20-14
page. Citylrown 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 ���e��u�ltturrr,
onng o the compms
uter, �������```SN OFIIf. ,q
use only the tab 1. Inspector: � �o? q�y��
key to move your JAM E S %ZPA
cursor-do not James D.Sears =� =�+'
use the return Name or inspector v t =�'
key.
CapewideEntere rises,LLC 4 :'•o �o;����
Company Name5I N S \ •
153 Commercial Street
Company Address
Mashpee MA 02649
Citylrown 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. 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
5-20-14
pedoes 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.
el d
t5lns.3113 We 5 Of fil Ins .SUbsurtace Sewage Usposal System•Page 1 of 17
May 21 1410:16a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required for every Centerville MA 02632 5-20-14
page. CiKrrown State Zip Code Date of Inspection
B. Certification (cant.)
Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments: ,
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N '❑ ND (Explain below):
I .
15ins•3113 Title 5 Official I:} nspecNar:Fo.'m:SuGsurraae Sewage Disposal System•Paga 2 of 1?
May 21 1410:16a p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal ISystem Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required for every Centerville NIA 02632 55-20-14
page, Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumpsialarms 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):
s ❑ broken pipes)are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
l
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
i
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins=3113 ,j Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 3 of 17
May 21 1410:16a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required for every Centerville MA 02632 5-20-14
page. City/Town 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 welt`.
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
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 1/2 day flow 401tis
t&ns'r 3013 Title 5 Of led InspeWon Farm:Subsurface Sewage Disposal System-Page 4 of 17
t:
May 21 1410:17a p.5
Commonwealth of Massachusetts
Title 5 Officials Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt .
Owner Owner's Name
require for
is Centerville MA 02632 5-20-14
required for every
page. Citylrown 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 N 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.
y
t5im•'5/13 Title 5 Ofifdal hVreaion Form:Sub3urra=a Sewage Olsposal System•Page 5 or 17
1
May 21 1410:17a p.6
' A '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is Centerville MA 02632 5-20-14
required for every
page, Cilyffown 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
Q ® 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?
0 ® 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?
s
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
El
® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The sie 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.
3
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)1310 CMR 15.302(5)]
D. System Information'
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310,CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins Vis 4 Title 5 ORdad Inspection Form:Subsurtace Sewage Disposal System-Page 8 of.7
i
May 21 1410:17a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required for every M Centerville A 02632 5-20-14
page. CltylTown State Zip Code Bate of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and three flows.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
J
' 2012-39,000Gal
Water meter readings, if available(last 2 years usage(gpd)): 2013-23,000Gal's
Detail:
Sump pump? ; ❑ Yes ® No
Last date of occupancy: NA
Date
Commercialllndustrial Flow Conditions:
Type of Establishment
Design flow (based on 310 CMR 15.203): Gallons 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:
151ns-313 Title 5 Official Inspection Force Subsurface Sewage Disposal Syslem•Page 7 of 17
v .•
}
May 21 1410:18a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form- Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt _
Owner Owner's Name
information is required for every Centerville MA 02632 5-20-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use'. Date
Other(describe below):
i
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;
® Septic tank; distribution box,sail absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
I
❑ 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):
151W 3113 TINe 5 Otficral In sMclan Form:Subsurface Sewage Disaasal Syslem•Page B of 17
i
May 21 14 10:18a p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner owner's Name -- ---+
information is required for every Centerville MA 02632 5-20-14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
1986 Permit #86-115 1 New D Box 5-14..
{
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
s
t 20,1
Depth below grade: fleet
r
Material of construction:
s
❑ 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 4" PVC SCH 40.
Septic Tank(locate on site plan):
u 10
Depth below grade: feet
Material of construction:
® concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain)
4
d
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: r
1000 Gal. Precast
Sludge depth: 1
15Ires-313 Title 5 Official inspection Form Subsurface Sewage Disposal System-Page 9 of 17
May 21 1410:18a .I p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required for every Centerville MA 02632 5-20-14
page. City/Town State Zip Code Date of inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness UP
Distance from top of scum to top of outlet tee or baffle 12"
t
e
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? Asbuilt-Tape-Plan
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level,tank and covers at 10". Inlet tee, outlet baffle. No sign of leakage or over
loading.
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
i51ns?3113 InS9 5 olfidd hispeclion Form Subsudece Sewage Disposal System-Page 10 of 17
i
5
i
May 21 1410:19a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required For every Centerville MA 02632 5-20-14
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.):
If
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
i
s
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
t
:sins-3/13 Title 5 Ofridal Inspedion Form:subsurface Sewage Disposal Syslem•Page 11 a 17
May 21 1410:19a p•12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is Centerville MA 02632 5-20-14
required for every
page. Cityffown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x21"-14",below grade w/one line out. Cover at 6" below grade. Box is new 5-14..
ti
s
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
r
}
* 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:
151ns-3113 Tile 5 Offidal kspedion Form:StbnMace Sewage Disposal System•Page 12 of 17
May 21 1410:19a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
630 South Main Street
Properly Address
Ruth Pratt
Owner Owner's Name
information isCenterville MA 02632 5-20-14
required for every
page. CityfTown Stale Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number
® leaching chambers number:
3
❑ 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 three flows w/4' stone. Flows are 19" below grade. Clean and dry.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer ,
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Ism' 3n3 TitleS Official Inspection Forrrr Subsuiace Sewage Disposal System•Page 13 of 17
i''
May 21 1410:20a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsuirface Sewage Disposal=System Form-Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is required For every Centerville MA 02632 6-20-14
page. CityrFown Stale 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.):
i
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
t5ins'3/13 Title 5 Official Inspection Form:SubsWace Sewage Oisposa System-Page 14 of 17
May 21 1410:20a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
_ 630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is
required for every Centerville MA 02632 5-20-14
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
A F�oNj-
4' 3;` o 0
-r
t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sawage Disposal System•Pape 15 of 17
May 21 1410:20a p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is
required for every Centerville MA 02632 5-20-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. 6' -
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: 4-8-82
Date
® Observed site(abutting propertytobservation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Plan 4-8-92/T.H. 6, T ADJ 1.7'
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
U.S.G.S.well T.S. 89 1.7'ADJ
You must describe how you established the high ground water elevation:
Hand Auger T.H.6'water, ADJ 4.5'. Bottom of flows at 3' below grade. Bottom of flows at 3' above
T.H., 1.5'above ADJ.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
151ns-3113 Title 5 Official Inspection Forth Subsurface Sewage Disposal System•Page t8 of 17
May 21 1410:21a p.17
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage DisposaUSystem Form-Not for Voluntary Assessments
r 630 South Main Street
Property Address
Ruth Pratt
Owner Owner's Name
information is
required for every Centerville MA 02632 5-20-14
page: City£rown 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 16 or attached in separate file
i
c
t5ins•3113 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 17 of 17
No. r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
o. PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS
appYiration for misposal 6pstem Construrtion j3erMit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. (03 0 SL e N A-C S-1- Owner's Name Address,and Tel.No.
Assessors Map/Parcel Mo to - 55 KA VAA&t0csryr-(?o)C—r
Installer's Name,Address,and Tel.No. 5 Cg-4,fl-1 -,%17 Designer's Name,Address,and Tel.No.
I)rpe of Building: A' 4
N
Dwelling No.of Bedrooms Lot Size I�` 3 � sq.ft. Garbage Grinder( )
Other Type of Building Q 19S D70!M PA_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided IV44 gpd
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)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt L
FS ed Date
Application Approved by Date L1130 2_Vd
Application Disapproved Date
for the following reasons
Permit No. '7014 —I,z Date Issued 0 2-ON
- No. IiLJ "t'-- 1 Fee�
`'.-•: •:;: THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppl(tation for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System,-[X Individual Components
Location Address or Lot No. 103 0 501 t4 X1 N s,- Owner's Name,Address,and Tel.No.
4SNJrMV1L-0 (::jAjt0(,-,j&l 514 61 MIC_K
Assessor's Map/Parcel ( 94P Q C f)- 515, KAT#::-,, P-4Tt-+ VA U&eouTr{f�T
Installer's Name,Address,and Tel.No. 3(Z Designer's Name,Address,and Tel.No.
G'-406kx 0 E' N/Ar
153 z- MSN-p +S
Type of Building:
Dwelling No.of Bedrooms #+ Lot Size 3e(�,3z- sq.ft. Garbage Grinder( )
Other Type of Building /,&7043.►Tl AL— No.of Persons Showers( ) Cafeteria( )
Other Fixtures P t
Design Flow(min.required) /1 gpd Design flow provided N4 gpd
Plan Date Number of sheets Revision Date
€ _ Title
� 1
r Size of Septic Tank Type of S.A.S.
F"F Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
?' -Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
s
Si ed
Date
Application Approved by Date 30 2-0
Application Disapproved Date
f f for the following reasons
,.
Permit No. Date Issued 0 2Q1
------- ------------ --- -------- ----------------- ----------- ------------- - --------------------------------------- -----
s TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )bypLLa�
at 4v3e-j SC)07W A,(d' 10 S CEN76CV/u cChas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ®I Z D#q
Installer (2APaa IX: 0J7E=CPaQ15ZFS !l C— Designer
°� #bedrooms �/14 ' Approved designnflow /} x gpd i
The issuance of this.pe6iit shall
jnot be construed as a guarantee that the system willr/injeti'on as designed.
Date T "~' 0�7 Inspector r' �: f 1`�•t f 1",�f (1� .A�)
- --------------------------------------------------------------------------------------------------------------------------------------
No. ZoI Z Fee /l1l�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( >() Upgrade( ) Abandon( )
System located at 6.30 S 0(- f MA/,V S T
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.
Provided:Cons ction must be completed within three years of the date of this permit.
Date q 14 Approved by / y
LOCATION SEWAGE PERMIT NO.
VIILLAGE
INSTA/LLER'S NA, ME L ADDRESS
OR OWNER
'' lb
� �
r ? Al
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
i.
r2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T�._.....0F......:.. - - ... KIP B�OVoo2
Appliratiun fur �iupuual urko Tonutrnr#iun Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: c
.... . �. :�::--! ................................. ........_.--- •....
Lo Address ® or
.. -- ----------------------•----•-•--..._.... . ...._••--•-.•. ---------...__.. .... ::....0
o Pr e
W ......••.....�i ----------------------------•--•-•---- � ------- A — ............
� Installer Address /1
d Type of Building Size Lot__Ml-C)p�.........Sq. feet
U Dwelling—No. of Bedrooms.....................3
....................... Attic ( ) Garbage Grinder (�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
A' Other fixtures ..............................................................................................
.....
--- ------------••-•...•-•-..........
�
W Design Flow...... �__.____.___.gallons per person per day. Total daily flow....................................:........gallons.
WSeptic Tank—Liquid capacity_ /tV.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (" Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------
----__-.
a'
ODescr>ption of Soil............ ..... ---
"�
WL................... ..
U N e of Re airs or Alterations—Answer when applicable________________ � ___._._ ___..._____...._........_... ._..................
�
:. r�,... r�N 1. �-7UG•.��-�.._°_I 1-- , ,,--� �'��_= �.�4g�t_? ..�...s-C rv�.....
Agreement: Z- c P7teoYdeS
e < � " N v�2 -,t/v G o � t D
The undersigned agrees to install the cribed Individual Sewage Disposal System in accordance with
the provisions of iITi U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificat of Compliance has beP issued by� th koard of health.
=
� u Signed....... ........................ =--...-•-------.................................... ... �� �...----•-
' —� 'atl
ppcation Approved By.................... -•--•- ........................ :.. ........................ ..
Date
Application Disapproved for the following reasons:..............................................................................................................
..-----•--•-•-•-•................•-------•---------...----------•...•-••------•-•----........--•------•--•-•-•-•-------....._ ....---•---•-------•-••••--•-•---••------•-----••••--••••...----.....---
Permit No............ ......�� _�_......__.__ Issued_...........................................
Date
..
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
1
.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH _
..............................................
Appliration for Biopoaal Works Tonstrnrtton Uprrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at- n D----- .....................
• Loc Address / 30 � or I�ty,No:
O �
A .e. .._.....
.......... .......e— ------------ --------------- ----------------- --------------..........
Installer Address
Type of Building �d l 06 Size Lot_.._.... 6.......... feet
�. Dwelling—No. of Bedrooms.................3.......................Expansion Attic ( ) Garbage Grinder (/7'p
Other—Type e of Building� YP g --------•--•---------------• No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures . —- ------------•--••-•----- ••••----
W Design Flow......... !1�............gallons per person per day. Total daily flow.................
> p ••-
...........................gallons.
WSeptic Tank—Liquid capacity../DO gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length......._............ Total leaching area....................sq. ft.
> Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box ( Dosing tank
( )
Z Percolation Test Results Performed by.......................................................................... Date........................................
1
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch
ff Depth of Test Pit.................... Depth to ground water........................
DDescription of Soil ...------•--•............................�..........1.............................................................................................
U •••-•----•-•••-----•---••-------------•---•---••.....••------•-•-•.....•----••••••--•--.......-•--•--•--•--••------.-----•-••---•------------•--
U N e of Repairs or Alterations—Answer when applicable_.____......1�1i 'v`'___..__._. `..........................
lC/U (��--�, �.. / ter ► ..l1,�,.......................................................Z �'� �
Agreement: =r `(-rrZ C.r I r JU _r--r C U .—'V ,.J c,- 1;t ry r.....................................................
r `"."r'�- i r rZ .. r- !� �- 't.t C / 'tl GAY-.1_r* t• 1- —"� �< jl
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued bythe ,oard of health.
- ' rf Signed---- >! f�,"�'C/��
1 ,C --------
D1 ation A roved B -- -----y'` �,i..�- �Date�A
PP PP Y _ ................
Date
Application Disapproved for the following reasons:.............................-•......................................•----....-----•------. •__•••---•,__
................................................••---------••---............--------............-----••---•....••---•-•••••-•••--•-•--•-•••••-•-------•--..............................................
Date
PermitNo.. ' ................--••••-• Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS rZ
BOARD OF HEALTH
................. .............OF.........
-- '�:........................................................-
Trrtifirate of Tontptittnrr
THIS IS TO"CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by1.�..�.........__....:._......_F.. �-� ............................. -----•---..........------...:::---•-------•-------------•----•---••---------------------..
Installer
at.......... . _ c7 �..1�.t_7 .... - -�i-
-._._.._._... ------•--- -•-----------------------------------•------------------•-.--•-_------------••---------
has been installed in accordance with the provisions of TITLE`-5`of The State Sanitary d;-/
s described in the
application for Disposal Works Construction Permit No.........� ...._..._?... dated_. _ . .........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UAR THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
/
DATE...............``-- ---------------------------------------- Inspector.......
nsPector..---.. ----------._...........----------••---------...-----..._...-•---------
THE COMMONWEALTH OF MASSACHUSETTS iJ
�BOARD OF HEALTH
No..�-t�?_.�.� ..............................
.....�...r..:�.^.. .........OF.............. ....................c , .................. ..............
_.....
FEE.--...2.............
11ioposal Workii Tonsfrnrtion "Prrntit
Permission is hereby-granted........2__>: :�-_ .._....� ''..�.4U__+_......._..
•----•.................................................................
to Construct or Repair ( ) an Individual Sewage Disposal System
at No............. (�)- 1
-------• .......-•-•-••--....�:•• ...-. n 1 =-------------------•-•-•------.............---......---.....----•----•---•----.........
Street -
as shown on the application for Disposal Works Construction Permit No.�h..! :%Date z
........................... ' , ._.. '. ._ .... r ...............«
Board of Health
DATE.............
1
9.----•------------------------ ,
FORM 1255 A. M. SULKIN,(INC., BOSTON
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville,Massachusetts 02655(Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
March 6 , 1986
Town of Barnstable
Board of Health
367 Main Street
Hyannis , MA 02601
RE : Pratt Residence
630 S. Main ST
Centerville
Dear Board :
In accordance with the terms of the Variance for
the Pratt residence, I have conducted on- site inspection
and supervision of the installation .of the septic system.
The system has been installed in accordance with design .
I trust that this meets your present needs .
Very truly yours ,
Peter Sullivan, P . E.
Baxter & Nye, Inc.
PS/fmj
OF
PETER
SULLIVAN y
No.29733
s$IONAL ENS'
MEMBERS
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AmEWCAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
. 7
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