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Home My WebLink About0686 SOUTH MAIN STREET - Health 686 SOUTH MAIN ST Centerville (aka 700-cottage) , A = 186 — 037— 001 a r. No. 42101/3 ORA ESSELTE 10% O O O O r 4 �I a r I _fJ K i 11 If1i� I !ww R �;j Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfiratiou for Misposar *pstem Coustrurtion permit Application for a Permit to Construct( ) Repair()< Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. &1?�, S { "Ij :5 Owner's Name,Address,and Tel.No. ` it tGt�trtE� Ib►vrq� ��C�c:KS Assessor's Map/Parcel k 1 00 �560--" e4AW 57 Installer's Name,Address,and Tel.No. $®19-!(77- 827 7 Designer's Name,Address,and Tel.No. dAP,15W60C5-1AC46V_T L3 00A 0-0 ., �1A c Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �J gpd Design flow provided Aj 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) uck) y, LO(Tt4 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 Health. Si d Date I (~ l 3 .Application Approved by Date Application Disapproved by Date for the following reasons Permit No. c9D 3 Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Disposal 6pstem Construrtion Permit Application for a Permit to Construct( ) Repair O ' Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. t'o �o 5t�c3ttf >V Z" R i c AjVW4; S EGCRSc 0J Assessor's Map/Parcel Installer's Name,Address,and el.No. 508_q77_ g7-� Designer's Name,Address,and Tel.No. P1EccJ�G�F2p T 64,4Z Ca , // Type of Building: Dwelling No.of Bedrooms La Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided A/' gpd Plan Date Number of sheets Revision Date .0, Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) c�- L Date last inspected: .4 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 Health. Sig Date IJ Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by 111 r�L4f-A� 6 �- —QEa�—C��, ,l at / /_ C,°X�-T2E ��/-�- e-��/i,� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N -` dated Installer/ Designer #bedrooms Approved design flow /�/'/� and The issuance of this permit s a 1 not be construed as a guarantee that the system will functio as desi ned. C Date III, h 11 Inspector ti,, > . No. , Fee J7 . w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS \� 30isposal *pstem ConBtrULtion Vermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at / / S' � Ailli,. 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. f Provided:Construction must be completed within three years of the date of thi permit. .---~--- Date // Approved f I �P Y Commonwealth of Massachusetts Title 5 Official Inspection Form t, Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 686 South Main Street( Cottage) Property Address tf Richard &Ann Segerson Owner Owner's Name / required Information requir Centerville V MA 02632 11-19-19 redd Ctill for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important,When filling out forms A. Inspector Information on the computer, James D.Sears use only the tab key to move your Name of Inspector cursor-do not Capewide Enterprises use the return Company Name key. Commercial Street Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails /l - nerAo- 11-20-19 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. tNnsp.dac•rev.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Z a5ed I xezl dH Z17:1,1, 660Z l.Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 686 South Main Street( Cottage) Property Address _Richard &Ann Segerson Owner Owner's Name information equiretlo re Centerville MA 02632 11-19-19 required for every page. City/Town State Zip Code Date of Inspectlon 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: The system is a 1500 Gal. Tank D Box and two chamber's 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 oomplying 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): Mwp.doc•rev.T/26/2D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 £ a5ed xed dH ZIVU 660Z I,Z AON Commonwealth of Massachusetts t: Title 5 Official Inspection Form Id Subsurface Sewage Disposal System Form Not for Voluntary Assessments .�~ 686 South Main Street( Cottage) Property Address Richard&Ann Segerson Owner Owner's Name information is Centerville MA 02632 11-19-19 requiredd far every Me, City/Town 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: L V t5insp.doc rev.7/2812018 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal Syslem•Page 3 of 18 abed xeJ dH 660Z 62 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owners Name information is required for every Centerville MA 02632 11-19-19 page. City/Town 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 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 analysis of the anal is 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 u9insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page d of 16 5 a5ed xe� dH Zb:l.6 660Z 6Z AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owners Name information is required for every Centerville MA 02632 11-19-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) 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 owapief is less than 6° below invert or available volume is less than '/z day flow 4 EAMwG ' ❑ ® 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 y , p 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 ar s.. 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 C.4. 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 c5lnsp.doc-rev.7/26/2018 .Title 5 DRidaI Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 9 a5ed xeJ dH Z1VU 660Z I,Z AoN , cam\ Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 666 South Main Street(Cottage) Property Address _Richard &Ann Segerson Owner Owner's Name information Is required for every Centerville MA 02632 11-19-19 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 a1f inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner (and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ' ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] I t5insp.doc-rev.712 812 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 16 L a5ed xe:1 dH Zt7U 660Z I,Z ^oN Commonwealth of Massachusetts l Title 5 official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street(Cottage) Property Address Richard &Ann Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-19-19 page. City(Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 Description: 1500 Gal. Tank D Box and two charnber's. Number of current residents: 0 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 ears usage 2017-131,000Gal g ( y g (gpd))' 2018-111,000GaI s Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date t5insp.doc•rev.7!26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r 9 a5ed xed dH £bU 660Z 62 AcN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street(Cottage) L Property Address Richard &Ann Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-19-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercialllndustrial 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Mnsp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurlace Sewage Disposal System-Page 8 of 18 6 a5ed xe� dH Et U 660Z 62 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street(Cottage) Property Address Richard &Ann Segerson Owner Owner's Name requinform r on is Centerville MA 02632 11-19-19 requiredd for every page. City/Town 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/Altemative 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 PP of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1996 Permit # 96-168 /11-2019 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 23" 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. t5insp.doc•rev.7/2612018 Title B Official Inspectlon Form:Subsurface Sewage Disposal System-Page 9 of 16 06 abed xeJ dH bt U 61.0Z i,Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owner's Name information equir do re Centerville MA 02632 11-19-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 13" 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: 1500 Gal. Precast H-10 1, l Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 011 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape 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 13". In and outlet tee's.No sign of leakage or over loading. t5insp.doc•rev.712612M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 W.18 I,I, abed xeJ dH tb:1.6 6OZ 1•2 AoN Commonwealth of Massachusetts ,? Title-5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r rr V 686 South Main Street(Cottage) Property Address Richard &Ann Segerson Owner Owner's Name information Is required for every Centerville MA 02632 11-19-19 page. City/Town 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): Dimensions: Scum thickness Distance from top of scum to top of outlet tee cr 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): Dimensions: Capacity: gallons Design Flow: gallons per day t5inap.doc rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 II el, abed xed dH bb 66 660Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-19-19 page. Citylrown 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.): *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 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"x16"-18"below grade wlone line out. Box is new 11-2019 wlcover at 6". I t5insp.doc•rev.7.12W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 �� abed. xed dH bb:61• 660Z I,Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owners Name information equireto re Centerville MA 02632 11-19-19 required for every 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.): *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: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 b i, a5ed xed dH trb4 l• 6 60Z I Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments F,. 686 South Main Street( Cottage) Properly Address Richard &Ann Segerson Owner Owner's Name information is Centerville MA 02632 11-19-19 required for every page. City/Town 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.): Leaching is two chamber's. Ck D Box and camera out line. No sign of over loading or solid carry over. 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.): 16insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 5 abed xed dH Sb l6 660Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �9�. -V'l 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-19-19 page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) 13. 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.): 15msp.doc rev.7128l2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 19 9t a5ed x2J dH gtU 660Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street(Cottage) _ Property Address Richard &Ann Segerson Owner Owner's Name Information Is Centerville MA 02632 11-19-19 required for every ---•------------- page. CityfTown 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 If-1-- 1ta-in2affac on canar`ataly t i A � f t 1:0 T i I R,V w P� f i l 1 t tSlne 3r13 Tile s Mis Mopeelien Form:Sulaurmce 31W390 alixul sYnen 9e0015 at17 g� a5ed xe AO � dH Sb�l•6 6 60Z 6Z N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /y 686 South Main Street( Cottage) Property Address _Richard &Ann Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-19-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 15' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date . ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Abbuting property drop's off some 15'lot high. Bottom of chamber's at 4' below grade. Bottom of chambers at 11'above abbuting property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15lnsp dm•rev.7/2 6120 1 6 Title 5 Ofk4W Inspection FDrm:Subsurface Sewage Disposal System•Page 17 or 16 66 a5ed xeJ dH 9b:U WE 6Z ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ly 686 South Main Street( Cottage) Property Address Richard &Ann Segerson Owner owner's Name information is required for every Centerville MA 02632 11-19-19 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 G RAb c114MBfR`s r fr N� t5insp.doc-rev.7/2612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 18 of 18 0Z a6ed xed dH W 6 6 6 60Z 6Z AON 1 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 686 South Main Street 3> Property Address �-. 700 South Main LLC Owner Owner's Name information is Centerville ✓ Ma. 02632 02/17/2017 required for every page. City/Town State Zip Code Date of Inspection f.a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections 4:1 Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority f��k a 02/18/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 4otje,0,(1V � Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GM , 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has a H-10 1500 gallon septic tank and a H-10 D-Box with two 330 cultec rechargers with no visable signs of past hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N FIND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name required fo is Centerville Ma. 02632 02/17/2017 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No 9 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is Centerville Ma. 02632 02/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Fall 2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 5-6-1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 191, 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.): Septic Tank(locate on site plan): 11" 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: Standard H-10 1500 gallon Sludge depth: 3" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 35 Distance from bottom of scum to bottom of outlet tee or baffle 5" i How were dimensions determined? 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.): I would recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local septic pumping Co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is Centerville Ma. 02632 02/17/2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts H w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Two Cultec 330 ❑ 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.): At the time of the inspection the leaching was dry and there were no visable signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 686 South Main Street M Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A R 3 _L0 Ve- w" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 686 South Main Street Property Address 700 South Main LLC Owner Owner's Name information is required for every Centerville Ma. 02632 02/17/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file /l P/JS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joel Kubick v I use the return Name of Inspector key. Holmes and McGrath, Inc. r� Company Name 205 Worcester Court, Unit A4 Company Address Falmouth MA 02540 City/Town State Zip Code 508-548-3564 MA SI #4244 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Nov. 13, 2013 Inspector' ig ature Date The system inspector shall submit a copy of this inspection.report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. d 010� t5ins•09/08 Title 5 Official Inspectiod.Form: bsu ace Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B System Conditionally Passes: Y Y ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the.existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if. the system is failing to protect public health, safety or the environment. 1 System will.pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 dayflow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) - Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To.be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D.: Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system Is within 200 feet of a tributary to a surface drinking water supply E ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is Barnstable MA 02632 Nov. 13, 2013 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑ Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ElDetermined in the field (if any of the failure criteria related to.Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 (assessed) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is Barnstable MA 02632 Nov. 13 2013 required for every � � page. City/Town State Zip Code Date of Inspection D. System Information Description: Main House Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 288 9 ( Y 9 (gpd)): Detail: 288 gpd average between main house, cottage, and irrigation.for 2011 &2012. Sump pump? ❑ Yes ® No Last date of occupancy: 10/2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No - Industrial:waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is Barnstable MA 02632 Nov. 13, 2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. CityrTo`^n State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 17 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal _❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 10'6"x5'8"x5'8" Dimensions: 8" Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 0 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 18" How were dimensions determined? 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 appears structurally sound, outlet baffle in good condition. Liquid at working level. Pumping every 2 years is recommended depending on use. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): 1 outlet pipe. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Shown on as-built. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. Cultec Recharger 330 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure or ponding observed. Vegetation appears normal. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 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 �. � � � \ �\ \ems ��•�� \ t Approx r P / Septio As Deck \Q 07008Cat I �J \ t $etw t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 11.8' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Fax from Sullivan Engineering dated 12/15/2005 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Fax information describes an observed maximum groundwater elevation at full moon tidal cycle at elevation 3.19. Previous Title 5 inspection (12/15/04)shows bottom of SAS 4' below surface. Ground above system is at elevation 19'+/-, therefore bottom of SAS is at elev. 15'+/-which provides approximately 11.8' spearation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form::Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 700 South Main Street-Cottage Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is Barnstable MA 02632 Nov. 13, 2013 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file J. ►5 Mice riU M t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Flynn, Judith From: Flynn, Judith Sent: Wednesday, November 16, 2005 10:24 AM To: pjclargo@webtv.net Subject: E-mail 11/16/05 4:35AM Dr. Conniff: I have pulled the file fo 70 . South Main Street - Passed septic inspection 12/1 � �.� CO-A South—M Street,1(co fa{ e)ssed septic inspection 12/15/04l 716 Sou —'l�iain Street - "FAILED INSPECTION" 5/3/02 - A letter of non compliance was sent on March 1st 2005 informing them that the system has been in a failed state for more than two (2) years. - They were ordered to submitt to this office a plan of proposed replacement septic system components (s) within ninty (90) days of receipt of this letter. - They were also ordered to upgrade or replace the septic system within six (6) months (180) days of receipt of this letter. Dr Conniff you are more than welcom to come in and peruse they files at any time. I will be happy to show you our file system and answer any questions you may have. Judith iY CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAN_SI I, Joseph P. Maeomher Tr , hereby certify that the application for disposal works construction permit signed by me dated 5/1 /96 , concerning the . property located at 700A South Main .tree meets all of the following criteria: Centerville ,Mass . • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is ',4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: 5/1 96 {� LICEN SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. r" 1 TOWN OF BARNSTABLE LOCATION Row -C SEWAGE # VILLAGE" �s 1 SSOR'S MAP&LOT -4,+0 :7-T INSTALLER'S NAME&PHONE NO. !3 , *$'k XZ 446 f4f ,rs SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within'00 feeett g�qf�� acWg facility) Feet Furnished b., �' ' 1AW ��o-W InTa �� i �. �' i. � 4�ovs-e - � _ .�� __ t , No. Fee $ 40. 00 THE COMMONWEALTH OF MASSACHUSETTS P LIC HEALTH DIVISION -TOWN OF BARNSTABLE, M.ASSACHUSETTS 7, pplication for Migogar *pgtem Cow6truction Perronion is hereby made for a Permit to Construct( )or Repait%XX)an On-site Sewage6sposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 700A South Main Street Jack Williams Centerville,Mass. 02632 700 South Main Street Centerville Installer's Name,Address,and Tel.No. 5 0 8_7 7 5_3 8 Designer's Name,Address and Tel.No. 5 0 8_77'5_3 3 3 8 6 Centerville,Mass. 02632 , �.0 acomber Jr. J":.'P. Macomber Jr. Type of Building: DwellingXX No.of Bedrooms 2 Garbage Grinder(NO) Other Type of Building No. of Persons 2 Showers(1 ) CafeteriaN� ) Other Fixtures 1-water closet tlih� 2-sinks Design Flow 220 gallons per day. Calculated daily flow 2x1 10 gallons. Plan Date 5.111196 Number of sheets 2 Revision Date NA � Title Description of Soil Loamy sand to meelitim sanel Nature of Repairs or Alterations(Answer when applicable) Omit cesspool. Install 1-1 5 0 0 gallon tank 1-Distribution box 2-330 Rechargers. Packed in stone. With drip pipe. 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 d not to place the system in operation until a Certifi- cate of Compliance has been iss d by this ar f e th. Signed Date 5/1 /9 6 Application Approved by - Application Disapproved for the folowingreasons Permit No. qh -- �� _ Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certif irate of, Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replacedl(Xy)on by P Ma number Tr A for Jack Williams as 700A Smith Mai n Street CAnt carzri I 1 n,MA s s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 6 dated Use of this system is conditioned on compliance with the provisions set fort elow: $ 40.00 No.� - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Migo!6al 6pgtem Construction plermit Permission is hereby granted to._P_Mn a amba v- Xr, to construct( )repairX(XX)an On-site Sewage System located at 7nnA snntl1 Main strent (',(antsryilihe,M€t84 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: (2 l Approved by V (a D 3 7 t .. $ 40. 00 ,. No. C >+ Fee - THE COMMONWEALTH OF MASSACHUSE17S _ PU LIC HEALTH DIVISION =TOWN OF BARNSTABLE, MASSACHUSETTS �u - A ppli'tation for Migoot *patent Construction Perron, uR Ap ation is hereby made for a Permit to Construct( )or Repair�X)awon-site Sewage bispbsal System at: Location.Address or Lot No. Owner's Name,Address and Tel.No. 700A South Main Street Jack Williams t v 11 Ma 026 2 00 ouch Main StreetCenterville Cen er i e sa . 7 S ai ,� r 3 'Installer's Name,Address,and Tel.No. 5 0 8- 7'7 5- 38 , ' Designer's Name,Address and Tel.No. 5 0 8�-7 7 5—3 3 3 8 �0 hh6 Centery lle,Mass. 632' . .Iacomber Jr. JPP. Macomber Jr. A ry• I e M- c 2? 2 Type of Building: DwellingXX No.of Bedrooms 2 Garbage Grinder(NO) Other Type of Building No.of Persons 2 Showers(1 ') Cafeteriajq� Other Fixtures 1—water nl n At. tii1�_ 2_.g3 nlrG Design Flow 220 gallons per day. Calculated daily flow 2x1 1 0` i gallons. Plan Date 1 Number of sheets 2 Revision Date N A Title Description of Soil 4 Ei,- ,dj:UM sand Nature of Repairs or Alterations(Answer when applicable) Omit Ce8ep001. Install 1-1 500 gallon tank- 1-Distribution box 2-330 Rechargers. Packed in atone. With drip pipe.; t Date last inspected:' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system f in accordance with the provisions of Title 5 of the Environmental Code d not to place the system in operation until a Certifi-' cate of Compliance has been issu d by this ar of a th. ' Signed 9 Date 5/1/9 6 r Application Approved by 40a w Application Disapproved for the o lowing reasons Permit No. /� �n Date Issued " " /�C. s i