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HomeMy WebLinkAbout0700 SOUTH MAIN STREET - Health 700 South Main Street Centerville P � . A = 186 037 y. f.) *Pftd4vflovr .I I� II 4 1521/3 ORA 10010 P2 "=Mod i i t i I r j�{z�u� �'� � � � �� �, k h ., � - _ _ �. ji/+i+� F' �(, V (Q $ 40. 00 i No. 94/, �-� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migo5ar 6pgtem Construction Permit Application is hereby made for a e �Const ( )or Repair iXX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 700 South Main St eet Jack williams Centerville M 6 700 South Main Street Centerville Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.77 5—3 3 3 8 J.P.Macomber Jr. Box 66 J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Type of Building: Dwelling X No.of Bedrooms 6 Garbage Grinder(V0) Other , Type of Building No. of Persons 2 Showers( ) Cafeteria( ) Other Fixtures Design Flow 660 g.allon per d a-y-gallons per day. Calculated daily flow 6XI10 gallons. Plan Date 5111 .19A Number of sheets 2 Revision Date Title Description of Soil T.nam;r sand to Sand & gravel to—med-iultt sand Nature of Repairs or Alterations(Answer when applicable) !—2 000 gsrllsnjq_nk 1-Distributibution box 6-3330 Rechargers packed in stone. gmitvs®ssPeels. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this oar f e h. Signed,--. Date 5.11 .196 Application Approved by Application Disapprove for the following reasons Permit No. Date Issued� �� r " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS y,. Certificate of (Compliance F THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(XX)on by T P M c+omher Tr forie n, Williams as 700 o i P r " l has been constructed in accordance 1 with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated .�- - - Cb Use of this system is conditioned on compliance with the provisions set forth below: -�.�.� ��������������js'�a'i�iR`."C3Ti'iA..... .� ...i.niiTyy� �.S�L�r..�•,�'mo���r�rr�.. $ 40.00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migozaf *p.5tem Conelruction Permit Permission is hereby granted to .T.P_Mn c omhPr Jr. to construct( )repair' X�)an On-site Sewage System located at 700 South XnA n Strppt, C�ntar�ii 1 1 a_Ma i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by �•I �' 40. 00 � !' No. 1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01PPIicationj0r.zigPoga1 *pgtem (Congtruction 30ermit rwr f Application is hereby made for a Pe t to Const, t( )or Repair KX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 700 South Main St e®t "" Jack w,illiams Centerville Mass. 6 700 South Main Street Centerville Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.'7 7 5—3 3 3 8 � J.P.Macomber Jr. Box 66 1 J.P.Macomber Jr. Centerville,Genterville,Mass. 02632 Box 66 Centerville,Mass. 02632 „ Type of Building: Dwelling X No.of Bedrooms Fi Garbage Grinder( o) r( Other Type of Building No.of Persons 2 Showers( ) Cafeteria( ) Other Fixtures I /� s Design Flow 660 rp�a l� 1 on P gallons per day. Calculated daily flow 6M1 10 1 g�atlons. Plaii. Date 5/1 /g 6 Number of sheets F. Revision Date - Title i e.-• f rf i" Descri tion f Soil Ln a m v cm n r3 + a n d a P� -sr a p �o� � ( 1 s— r� 2 -to medium sendId ,. Nature of Repairs or Alterations(Answer when applicable)1��r1 n 1 i + n 1r 1—D i s t r but i bu L i o n box 3330-vRechargers packeds i i.°sta e. 0, y�O Fool , Date last inspected: -' r 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 ivCertifi- cate of Compliance has been iss d by this 'oar•VfeipthSignec/ Date Application Approved by r Application Disapprove for the following reasons r • s . - Permit No. Date Issued s 1-2000 gallon tank 1 -D-Box f y - 6 6-330 Rechargers Packed in stone. 700 South Main Street Centerville,Mass . 02632 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS I Joseph P. MaeombEr-Jr hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 700 South Main Street meets all of the Centerville,Mass . following criteria: • 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 inflow and/or change in use proposed • There are no variances requested or needed. SIGNED DATE: LICE ZED SEPTIC SYSTEM INSTALLER IN THIS 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]. i i7-0 1Y&_03i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S 700 South Main Street( Main House) Property Address Richard&Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. City/Town State Zip Code Date or 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. ,"��tpuuruUrpy�� Important,When filling out forms A. Inspector Information ts�-{� � a :�, '•�C '� on the computer, yG use only the tab James D.Sears = JA M ES key to move your Name of Inspector SEARS -+ u� cursor-do not Capewide Enterprises 'y*`• o . *.: use the return 3� F\,z—� � key. Company Name .y J�., RT1 153 Commercial Street �sshst,F s FNSPE _Q 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 I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 0ae_a4= 11-26-19 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. t5insp.doc•rev.7!2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 OZ a6ed xe:1 dH £Z:96 6MZ 9Z AoN I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Se4erson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 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 indlcated below. Comments: The system is a 2000 Gal. Pump Chamber Tank D Box and 12 chambers. 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): 15insp.doc•rev.7,28l2018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page of 16 l,Z a6ed xej dH VZ:96 6602 9Z AON f Commonwealth of Massachusetts �- Title 5 Official Inspection Form Wr C �y� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name Information is required for every Centerville MA 02632 11-26-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumpstalarms not operational_ System will pass with Board of Health approval if pumpslalarms 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 ❑ 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(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: 15insp.doc-rev,7:26/2018 ride 5 Offldal Inspection Form:Subsurface Sewage Oisposal System-Page 3 of 18 ZZ a6ed xeJ dH tZ96 660Z 9Z AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name Informrequired s Centerville MA 02632 11-26-19 required for every 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 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 t5inspAoc•rev.7i e=IB Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System-Pege 4 of 18 EZ a5ed xed dH bM6 660Z 9Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 4), 700 South Main Street( Main House) U Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 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 amompoW is less than 6" below invert or available volume is less than day flow A69C l/N6 ❑ ® 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 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 (lnterim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well t5insp.dot•rev.MW2018 Title 5 Offidel Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 t,Z a6ed xe� dH 92:91, 660Z 92 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.'' 700 South Main Street(Main House) Property Address Richard &Anne Segerson Owner owner's Name information is required for every Centerville MA 02632 11-26-19 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 all 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 NIA) ® ❑ 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 5Z a6ed xeJ dH 9Z:96 61,0Z 9E ^oN c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Lv Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Description: 2000 Gal. Tank-Pump chamber D Box and 12 chamber'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 years usage(gpd)): 2017-326,000GaI 2018-524,000 Gal's Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date (Sinsp.doc•rev.7!26!2018 Title 5 Dlricial Inspection Form.Subsurface Sewage Disposal System•Page 7 of 18 92 a6ed xed dH 9F:96 61.0Z 9Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatslpersons/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 occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: 11-2019 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.7lmacia Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 8 of 18 LZ a6ed xed dH LZ:96 U0Z 92 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name Information is required for every Centerville MA 02632 11-26-19 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/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: 1996 Permit # 96- 169. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30" 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 gZ a6ed xej dH K:91, 61.0Z 9Z AoN Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 per. CityfrDwn State Zip Code Date of Inspection D. System information (coot.) 6. Septic Tank(locate on site plan): Depth below grade: 20" 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: 2000 Gal. Precast H-10 Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" 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 16" How were dimensions determined? Asbuilt-TapeSludge 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 are 20" below grade. In and outlet tee's. No sign of leakage . Note: Tank maint. Pumping after inspection. t5insp.doc-rev.7012018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 6Z abed xeJ dH 6E:96 61•0Z 9E ^oN c Commonwealth of Massachusetts Title 5 Official Inspection Form Ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,✓ 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 per. CityfTown 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 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.): 6. 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 t5lnsp.doc•rev.7/2612 0 1 8 Tlde 5 Official Inspection Forth:Subsurface Setvage Disposal System•Page 11 of 18 0� a6ed xed dH 6Z:96 660Z 92 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cons) 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"-16"below grade. Box is clean and solid w/two line's out. No sign of over loading or solid carry over. t5insp.doc•rev,712612018 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 6£ a6ed xeJ dH 06:91, 660Z 9Z AON Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments y� 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 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.): Pump chamber at 1' below grade w/steel cover at 9". Pump and alarm working. 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: 12 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ZE a6ed xed dH OE:96 61.0Z 9Z ^oN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information Is required for every Centerville MA 02632 11-26-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is (12 chamber's.) Two set's of 6 each row. Ck D Box and camera out line's. 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.): t5inspAoc•rev.7i2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 E£ a5ed xed dH l£5 6 6 60Z 92 ^oN I Commonwealth of Massachusetts Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c' 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. Cilly/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5insp.doc•rev.7/26/2018 Title 5 Mist Inspection Forth:Su6st.rface Sewage Disposal System•Page 15 of 18 b£ a6ed xed dH 6E:S 6 6 60Z 9Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments WWI 700 South Main Street( Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 - page. cityrrown 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 .! Jr r N f t f t5insp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 5£ a6ed xe:1 dH Z£:96 660E 9Z AON - c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 v 700 South Main Street(Main House) Property Address Richard &Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 8 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: Auger T.H. Who G.W..Bottom leaching at 4'below grade. Bottom of leaching at 4'above T.H. Depth. Before filingthis Inspection Report, lease see Report Completeness Checklist on next page. P Po P t5insp.doc-rev.712 612 0 1 8 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 17 of 16 g£ a5ed xe:1 dH ££:96 660Z 9E AoN c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 700 South Main Street( Main House) Property Address Richard&Anne Segerson Owner Owner's Name information is required for every Centerville MA 02632 11-26-19 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 Not 7d � Q p oM 8' A CACHO vt Gw t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 or 18 L£ a5ed xeJ dH ££:96 61.0Z 92 AoN f Commonwealth of Massachusetts • W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street- Main House Property Address t ; William J. Goldenberg and Susan Nelli an Owner Owner's Name information is -& r able, MA 02632 Nov. 13, 2013 required for every page. City/Town State Zip Code Date of Inspection LAJ 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 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joel Kubick \J V use the return Name of Inspector key. Holmes and McGrath, Inc. 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 Inspect ignature Date T e 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 t5ins•09/08 Title 5 Official Inspe ffnm:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street- Main House 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: ® 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: 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): l5ins•09/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 700 South Main Street- Main House 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 Y Commonwealth of Massachusetts L W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 700 South Main Street- Main House Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. CitylTown 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Z. 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System•Page 4 of 17 r' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 700 South Main Street- Main House 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 the system is located in a nitrogen sensitive area (interim Wellhead.Protection ❑ ❑ Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall:upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 700 South Main Street- Main House 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 C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑ Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 6 Number of bedrooms (actual): 3(assessed) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 660 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street- Main House 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 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: Date 3 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 700 South Main Street- Main House 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.) 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): I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 700 South Main Street- Main House Property Address William J. Goldenberg and Susan Nelligan Owner Owner's Name information is required for every Barnstable MA 02632 Nov. 13, 2013 page. CitylTown 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 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.): i Tank locate on site plan): Septic ( p ) Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'6"wx5'8h"x12' long Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 700 South Main Street- Main House 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 (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 700 South Main Street- Main House 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 (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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 700 South Main Street- Main House 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.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert of, 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.): 2 outlet pipes, but only one had a Speed Leveler. An additional Speed leveler is recommended although the d-box is pumped to and any minor difference is not as critical as a gravity system. 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.): Pump floats in good, clean condition. No solid carryover observed from the septic tank. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Shown on as-built. t5ins•09108 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- Main House 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: 12 ❑ 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 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 700 South Main Street- Main House 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 (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 700 South Main Street- Main House 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.) 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 Lam 00 .Pam � t \...••`:.. \ -- _ .-_ .� ",tryS. ® ... N Approx / Septic `a tem :.:: ys Eteo gftck WotK < , (by TOB) / Pa i P / V t sty � w 2 001fo9 t i t5ins 09/OS Title 5 Offidal 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- Main House 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 (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4'2 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. 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 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 700 South Main Street- Main House 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 E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �.i�vTn�►c�- C��N� ICI e o � MAW-'Mu�'1 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 12/15/2005 17:34 5084283115 SULLIVAN ENG INC PAGE 01 Sullivan Engineer-ing Inc. z' Parker Road, Osterville 508-428-3344 fax 508-428-3115 Fm Tin Barnstable Board Of Health From Peter Sullivan/John O'Dea Fam SM79045304 1009ae: 1 Pim 5084 62-4644 Drtida 12115MS Reg 700 South Maln Street,Centerville CCz C.H.Newton Butlers 508%%84330 Wer Review Plemre Co/wrleuR Please Rely Please Reayale Please be advised that per your request we have determined the bottom of the existing 125 rechargers for the main house are located at elevation 7.39, and the observed maximum groundwater elevation, which occurred today (121192005) during a full moon tidal cycle at approximately 7:05 a.m., is located at elevation 3.19. This equates to a greater than 4' separation between the bottom of the leaching facility and the observed maximum groundwater elevation. Based on this information, and a Septic Inspection of the system performed on 12/15/04 by J.P. Macomber& Son Inc. the existing system does not appear to meet any of criteria outlined in The Code of Barnstable Chapter 360 Section 20 that would cause the Board of Health to require the repair or replacement of this of-site sewage disposal system. Please disregard the previous fax which had a mathematical error. > ' I trust this meets your present needs. Please feel free to call N you have any questions. John O'Dea � I f i (-� + � M l; t 12/15/2005 16:23 5084283115 SULLIVAN ENG INC PAGE 01 EngineeringStillivan 7 Parker • • , Osterville 1. • Fax Tbr Barnstable Board Of Health Emma Peter Sullivan/John O'Dea lFam 508-7904304 Payaa 1 Pbom 508-M-4844 Dade 12115W r 7700 South Main Street, Centerville ar C.N.Newton Builders 508-54&6= ------------ xFo►Review Please Cerrwnoet pas"Rvoy Place Raaycle Please be advised that per your request we have determined the bottom of the existing 125 rechargers for the main house are located at elevation 7.39, and the observed maximum groundwater elevation, which occurred today (12/1512005) during a full moon tidal cycle at approximately 7:05 a.m., is located at elevation 4.20, This equates to a greater than 4' separation between the bottom of the leaching facility and the observed maximum groundwater elevation. Based on this information, and a Septic Inspection of the system performed on 12/15/04 by J.P. Macomber& Son Inc. the existing system does not appear to meet any of criteria outlined in The Code of Barnstable Chapter 360 Section 20 that would cause the Board of Health to require the repair or replacement of this on-Me sewage disposal system. I trust this meets your present reads. Please feel free to call if you have any questions. John O'Dea R.ECE.,�s°�; ,�1AP DEC 2 3 Z004 LOT PARCEL z O 3� TOWN OF BARN TABLE V HFALTH UEPT. 1 DATE �zi�5io4 a 700 S. Mai St. PROPERTYa ,ADDRESS �w Cent e zv.i e ee Ma., � -70 On the above date;the:�ptic system at the address abov was Inspected. .. This system consists of the following:. 9.4-2000 gaiion zept.i.c tank. 2.4-1000 gaiion /lump chamge.¢., 3., 1 d.iztA:igut.ion .kox., 4., 12-125 2echa2ge2z.- Based on inspection, i certify the following conditions: 5.-7h.iz .ins a .t-itie dive -sePt.ic zyztem.' (95 code). 6. 7 �he ze t.ic h y,6.tem .i s .in /2ao/2e/c wo2k.ing o zde2 at the /22ezent t ime.� y 1 PJA SIGNATUR Name: Robert A. Pa01in1 Company: dosenh P. Macomber &Son Inc . Address: P. MADMAN' Centerville, Mass 026 2 Phone: 508 775.3338 or 60817 - 4 2-jOSEpH P. MACOMBER & SONt. INC& TankaCesspools-Leachflelds Pumped ,&...Installed Tdwn Sewer-Conneotlons P.O. Box 66 Centerville, MA.026.3'-0066 -7751330 . 7.7.5-6412- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OPPICE-OF E11MR rNM`YFNTAL AFFAIRS ' DEPARTMENT'OF I+.NVIRQNMUL PROTECTION A r "TITLE 5 OFFICIAL INSPECTION FORM-.N-0T FOR VOLUNTARY ASSESSMENTS SU$�SURFACE SEWAGE•DISPOSAL SYSTEM FORM FART•A CERTIFICATION. Property Address: ..70.0 S.,ft i n St Owner's Name: Le,&Zig. aka e.� n , Owner's Address: .S rL nzp , Date of Inspection: 12,11 5/O 4• Name of Inspector: leaseprint) R.P. fa a t Ep�o Company Name: , 2: l.AaaomAz&- & .Sawn .LAC. Mailing.Address: en e2v c e, a --02¢32 . Telephone Number: 5 Q-8-7 7 5-,3 3 3 8 CERTIFICATION STATEMENT . I certify that I have personally inspected the sewage disposal systgn,at this address and that"the.information reported below is true.,accurate and complete as of the time of the inspection.'f lie inspection was performed based on my training and experience in-the proper function and maintenance of on-bite sewage disposal systems.I am a DEP approved system inspector pursuant to�Section:15:340.of•T,itle s(31b CMR45-A00). The system: XX Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving•Authority Fai Inspector's Signatt re: Dito: The system inspector shall submit'a copy of this inspection repori to the-Approving Authority(Board of Health or DEP)within 30 days of completiug this inspection.If the system i.a,shai.d sy*m or has a design flow of 10,000 gpd or greater, the inspector and the system'owner.s1i Ysubmit the report to the appropriate regional•office of the DEP.The original should be sent tonft.system owner and copies sent to ttp buyer;if applicable,and the appM via 9 authority. Notes and Comments ****'phis report only describes conditions at the time of inspection-and under the conditions of use at-that time.This inspection does not address.bow the system will perform in the fgture under the same or different conditions of use. Page 2 of I 1 OFFICIAL INSPECTIONYORM NOT:FOR VOLUNTARY ASS'SESS14 tNTS SUBSURFACE SEWAtGE DISPOSAL.SYSTEM INSPECTION FORM � PART-A CERTIFICATION(continued) Property Address: 700 S -I'Iain St., Owner: f 1i k a 2.6 o n Date of Inspection: 12115104 Inspection S.nmmary: Check Ai C;D or.E/AL_AAYS�egmplete=all of Section D A. System Passes: no l 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 no* 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 Healtfi,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n o • The septic tank is metal and.over 2O years old*or the septic-tank(w:hether metal.or:not)is:structurally unsound,exhibits substantial.vinfiltratim or exfiltration.or tank failure.is:immirwnt: System will pass inspection if existing tank is replaced with'a complying septic tank-:as-Approved by the:Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: nQ 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): r broken.pipe(s).are replaced. . obstruction is removed distribution box is leveled or replaced ND explain: r no The system required pumping more than 4 times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: f Page 3 of 11 OFFICIAL INSItECTION FORM-NOT L'OR VOLIUNTARY TE IN nCT 6N RM TS SUBS•'l`JRFACE SFW-A•�CE 1DISROStAL SYS PARTA.. . CIERTIFICA ION'(6oritinued)' : Property Address: 7 0 U S.,(I a i n S .' Owner. O A Q J O / Ir n Q A nn Date of Inspection: C. Further Evaluation-is.Requii ed by the Board of Health: no Conditions,exist whichxequire ftuthet..evaluati¢n.by.the�Board:ofHealth;in•order,to;deteMine if-the system is failing to protect public.health, safety or the environment. A tbat the 1. System will�pasi unless Board-of.Re r whi haltb e will protect public headance lth,safety•aino the eisv raument: system is-mot furre oning iit.a a o Cesspool or privy is.within 50 feet of a.surface water etated wetland or a salt marsh. n o Cesspool or privy is within 50.feet of a bordering veg ; 2. S Y stem will fail unless the Board-of Health(and Public Water aSupplier e pl er'envi odetenmines:that the . system is functioning in a mariner.that protects thrpttblic health, _ The system has aseptic tic faille and soil absorption system-(SAS).-and the SAS is within 100 feetof a no p surface-water supply or.,.tributary to a.surface water supply. no The system-hasP•a.se•fic tank and SAS and the,,SAS is�wlfliin a Zone 1 of a-public watersupply. • no The system-has a septic tank and•�AS*andtheSAS iswithin:.50 feet of a private watersupply well. no The system has a septic tank and SAS and the SAS is tancc an 100 feetbut SO feet ox:iriore froinl a private water supply well",Method used to determine dis r colifon **This system passes if the well water analysis,pethanthe well s P certified free from-pollution fro,mt that facility and bacteria and volatile organic compounds indicatesrovided that no other the presence of ammonia nitrogen and nitrate nitrogen is oqual to or.less than 5 ppm,.p failure criteria are triggered.'A copy of the analysis must be attached to•ttlis form. 3. Other: Page 4 of I 1 OFFICIAL-INSPECTIOrN FORM NOTYORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 700 S.,Nain S�t_., Cen�e2v.�.Q.�e. (�a.• . Owner: Date of Inspection: 12/9 D. System Failure Criteria applicable to all systems:. You must indicate"yes".or"no"to.each.ofthe:following:for all-inspections, Yes No — . x Backup of sewage:intoIat' Jty.:or system.component.due-_to overloaded:ot clogged SAS...or.cesspool x* Discharge:or-ponding of effluent to the,surface r athe.grpund o...surfacematers due to.an overloaded or clogged SAS or cesspool _ x Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ x-Liquid depth in-cesspool is less than:6"below invert or,availably volume is less than'h.day flow _ x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ' x Any portion of.the SAS;cesspool or privy is below High ground water elevation. _ x Any_portion of cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface T water supply. x Any portion,:ofa cesspool-or-privy is within,a:Zone!1.of. public.well.. _ x Any portion of a cesspool-or privy is within.50 feet of a private water supply well. _ x 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 coliform bacteria and volatile organic.compounds 4fldicates that the well is.free from pollutionjrom:tltat.facflity and.thq presence�of ammonia nitrogen and nitrate nitrogen is equal to or less than S-ppm,provided that no other failure criteria are-triggered-.A copy of the analysis must be attached.to this forM..] n° -(Yes/No)The system falls.I.have determined that-one or.more-of:the:aibove.failure:criteria exist as described in 310 CMR 15.303,therefore the.system-fails.The system owner.should contact the Board of I•ioaith-to determine what will be-necessary to correct the failure.. E. Large Systems: To be considered a large system the:system must.serve.a>faeility,with a design flow of hO;OU.O gpd to 15;000 gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria-above) yes nq • the-system is within 400 feet of a surface drinking-water supply x the system.is within 206 feet of a tributary to a surface drinking water supply x the:system is located In a nitrogen sensitive area Qnterim 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 it 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 tender Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional•office of the Department. 4 Page 5 of 11 OFFI'CfiAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS $$SURFACE-SEWAGE DISPOSAUSYSTEM INSPECTION FORM PART 9 CIiECKLIST Property Address: 700 S'.�Nain SL Owner: l v t p v lq i k n ..t o n Date of Inspection: Check if the followin have been done.You must indicate` s"or 'no"as#o each.of the oilowin 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? x _ Has the system received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as part of th� inspection? x Were as built plans of the system'obtained and examined?(If they were not available hote as N/A) x Was the facility or-dwelling inspected for signs of sewage backup? x Was the site inspected for signs of break out? x . _ Were all system components, excluding the SAS, located on site.`?. — opened,and the interior.of the tank inspected for the condition Were the septic tank manholes uncovered, of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? x _ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS).on the site.has been determined based on: Yes no x Existing information:For example,a plan at the Board of.Health. _ x 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(3)(b)] • 5 Page 6 of I 1 OFFICIAL.�1SPECTIOAI;FORM`-NOT FOR VOLUNTARY ASSESSMENT'S SIMSURFACE SEWAGE DISPOSAL SYSTMINSPEETION FORM � PART.0 SYSTEM-.INFORMATION Property Address: 00 S. 6a in Si_ Cen.tP.2U.i.P_.ee. Ala. Owner: Ni_kaiAon Date of Inspection:-12/9.51 QY, , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_,, ( ,Number of bedrooms(actual): 6 DESIG9.flow based on'31ft CNOt 15.203':(for example:•1 I0 gpd z#-of bedrooiiisy: 1.10 x 6=6 6 0 gl?d Number of current residents: .: Z Does•Tesidence have a garbage grinder(yes or no):_n o Is laundry on a separate sewage.system.(yes or.no)'&a_ [if yes separate inspection required] Laundry system inspected(yes or no):yh Seasonal use:(yes or no): a 00 at�tS ���/d®� �j P'�` 3 Water meter readings, if available(last 2 years usage(gpd)):,Q0V4 =/� Sump pum (Yes or no): no Last date of occupancy:fz 2 e.6 e n t COMMERCIALjO­ ktJSTRIAL Type of estah) annt: n '. Design flow.( s on310 CMR 15.203): na gpd Basis.of d�s.H".. ow(seats/persons/sgft,etc.):, na Grease trap•present(yes or no)-,n o Industrial waste holding tank present.(yes or no):n¢ Non-sanitary waste discharged to the Title 5 system•(yes or no):na Water..meter readings,if available: na Lastdate of occupancy/use: •n a OTHER(describe):. GENERAL INF09MATION Pumping Records Source of information: _1.�P.,Nacom9e2 and 36a Was system pumped as part of the inspection(yes or no): n o If yes,volume pumped: 2000 gallons--How was quantity pumped determined? m.e a s u 2 e d Reason for.p..umping: ('1 a i n t a n c e .' 9/Z 5/0 4 ,..._. .: .. TYPE OF SYSTEM �x Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy v _Shared system(yes or no)(if yes,attach previous inspection records,if any _Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a.copy.of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: .in,daiied 9 9 9 6 Were sewage odors detected when arriving at the site(yes or no):n o Page 7 of 11 e OFFICIAL INSPE CTION FORM—NOT FOR VOL ' UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 700 S.,Na.in St., CenterzvTe.Qe— Owner: Les-Ue /7jka.Vzon Date of Inspection: I)/15 I n 4 BUILDING SEWER(locate on site plan) Depth below grade: 1 6" Materials of construction:_cast ironxx 40 PVC_other(explain): Distance from private water supply well or suction line: 1.0' f Comments(on condition of joints;venting,evidence of leakage,etc.): System vented thzough hou,3e vents., `�. SEPTIC TANK:y e,3(locate on site plan) Depth below grade: 20 Material•of construction: . x concrete metal, fiberglass_polyethylene _other(explain) — If tank is-metal list age: no Is age confirmed by a Certificate of certificate) Compliance(yes or no):—(attach a copy of Dimensions: 6' 6"wade/5 ' k"h.igh/72'iond Sludge depth: tiz a c e Distance from top of sludge to bottom of outlet tee or baffle:t 2 a c e Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle:n o .3 c ura Distance from bottom of scum to Bottom of outlet tee or baffle: no .6 c u in How were dimensions determined; m o ri A u n v r/ Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural irate as related to outlet invert,evidence of leakage,etc.): gnty,liquid levels 2-3 1 Al U ZdAAGG ound.,No GREASE TRAP; no(locate on site plan) Depth below.grade:na , Material of construction:_concrete_metal fiberglass_polyethylene other (explain): n a — Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: n a Distance from bottom of scum to bottom of outlet tee or-baffle: n a Date of last pumping: na Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.): TMA i Tner�anfin»T7nrm �i�si�nnn 7 Page 8 of I I OFFICIAL INS-PECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS $SUKF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: lvn A, Ma., Owner: Date of Inspection: 12115•104 TIGHT or HOLDING TANK: no (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: na Materiel of construction: concrete metal fiberglass__jolyethylene_-_'__other(explain): Dimensions: na Capacity: . na __ gallons Design Flow: na gallons/day Alarm present(yes or no): HE Alarm level: na Alarm to working order(yes or no): Date of last pumping: na Comments(condition of ai.arm and float switches, etc,): 7 ;r,hf nn hnidin ank,6 not DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:ao 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.): ha,6 1-wo eaa<e2ae� , Teow -iz ec�uae.,No evidence o� leakage into n,i f L"-,No, guide ace o e hoi.cdz3 ca22yOve2., PUMP CHAMBER:rye& (locate on sife.plan) \, Pumps in working order(yes or no): _LP-2 Alarms in working order(yes or no): tL" Comments(note condition of pump chamber,condition of pumps and appurtenances, etc,): „m{ _hnma_�n_CL2,nyn/jb .6�2uctulta��u �sQund. .�� com/?onent'6 � _� n7nnn ,Inniting nRf P/(� , Y' 8 • Page 9 of I I OFFICIAL INSPECTION)FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 0 0 C lrI nLn .0 f Owner:. Date of Inspection: 9 19 5 l 4 SOIL ABSORPTION SYSTEM(SAS): .(locate on site plan,excavation nqt required)) If SAS not located explain why!. Type _leaching pits,number:— `. " leaching chambers,number:1 /9 Z 5 2 e c h a t y e 2,3. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: . _overflow cesspool,nu mber: _innovative/alternative'system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level ofponding, damp soil,condition of vegetation, etc.): Sand o f j.�No h e n,3 o h d/tauiic aiiulte., V e et at-.on aRpeapA noama.Z., CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: na Depth—top of liquid to inlet invert: na Depth of solids layer: na Depth of scum layer: na " Dimensions of cesspool: na Materials of construction: na Indication of groundwater.inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,eta): Ce%.b ooi's not ae'sen�. PRIVY: no (locate on site plan) Materials of construction: .na Dimensions: na Depth of solids: na Comments(note condition of soil, signs of hydraulic failure,level of ponding) condition of vegetation,etc.): ;9 a Page 10 of 11 O'J�'MC AE WSPF�T1QN•1�'QYtM---- NOT FOR'NA�I�11J1�TA�t'S�ASSESS�VIENT5 / SUSSLj] FACF,SEWAGEMISPOSAL SYSTEA .iNSLEC'i'30N:FQRIV'!k PART-Cr SYSTEM WFORMATI.ON(nontinued)' Property Address: 700 S.,M a-i a S�-., Cen7eay.i..2te Ma., Owner. Le,3,Ue Nika4,3on Date of Inspection: � • SKETCH OF SEWAGjE-DISPOSAL SYSTEM Pro We a sketch of the sewage disposal system including ties to at least two perinaneitt reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public'water supply enters.the building. T60 � -- 'y \ p\ )q 10 Page 11 of 1 I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ION FORM PART C SYSTEM INFORMATION(continued) Property Address: L n n c ,m om,i n a- _ ti Owner: / o,t11i o l7ikn�on Date of Inspection: ) 4 0.4 - A SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water_feet-- Please indicate.(check)all methods used to determine the high ground water elevation: n o Obtained from system design plans on record-If checked,date of design plan rgviewed: y e%Observed site(abutting property/observation hole within 150 feet of.SAS) Checked with local Board of Health-explain: a z-t?u i.-f t 2 1 Checked:with local excavators,installers-.(attach documentation) Accessed USGS database:explain: h t t!z •t o wn P.a 2 h,s t o e. m u''u z �-. You must describe how you established the high ground water elevation: used;Gahert & Miller model 12 1 used-USGS observation w 1 -mlial -ran used. Technica u e - ar - wa er e eva ions. Beet ' Groundwater: Feet Beiow Bottom of Pit 14igh Groundwater Adjustment 1.8 ft per F;inapte�Method Therefore,the.vertical.separation distance betwCen the bottom of the leaching pit and the adjusted groundwater table is 1 feet: 11 „,,.r.,r•.,rnr—..,...,.... r,rRn* a-Wrre"w„ WARD OF HEA.LT11 '1'UNN OF B,_ar__ns 41-e ” CTION FORM - PART D•- GE11TIFICATION SUI)8U)HFACF 9FNAGF DISPOA�A•L SYSTEM 1H81 F � � ��r,_•�•„,• _„ F••.t• -T••.-:,.—*• r•-:,+•*:•sr.+n•nn.•*�rrnrs+r:"-nn,- ..T`F'PL OR PfIINT GLEI+RLI'— PROPERTY I NSPGCT'ED STREET ADDRESS ASSESSORS MAP , DI OCK ANnD� PARCEL OWNER•' s NAME PART U - cEnTxrlCri 'ION NAME OF INSPECTOR COMPANY NAME Joseph P. Macomber & `Son Inc Bo COMPANY ADDRE55 tCentervi] Ia. Mass 02632 stag t I P stce 7o�n yr city 1.578 COMPANY TEUEPIiONE ( 50.8 ) 775-33-38 FAX ( 508 ) 790- CI?R'rI FICAT•ION. STATEMENT I certify that I .,have personally inspected the sewage • dieposa`l system n ;.this nddr.ess and that the inforinatio �rThnrit,nspection is �wascperformednand any complete as of the time of 4inspecti recommendations regard ui;grade•, maintenance , and repair are consistent with my' training and experience in the proper function and maintenance of on site sewage disposal systems . . Check one : , System: MASSED The inspection which I have condu-c,-ted has not found protecformation which indicates th at th.e system fails toadequately Ilealtll or thF valuated jj�are assdstated in the FAILURE303 ,CRITERIAfailure section 0 . criteria not evaluated are a this form . System FAILED ic11 T have conc�t�cted h.as found that the system fails The inspection w)1 protect the E)tIb.iic health tl� and the ally notedtonnPARTOCd accordance Title 5 , 310 GO 15 , 3Q3 , and as speciflcai. y ` CRITERIA of this inspection for.0-, ate Inspector Signature . a !ne copy of this G rc.tf'-Cation moustt be p, Qvided to the OWNER, the DUYER ,P f t1liseT) and Ghe 130l)R OF ( where aNP r * .Ii the inspection FAILED , Glide- owner orop.©rator. shall upgrado ' the uiredm within one year of the dote of the inspection, unless allowed or req otherwise as provided in 3.10 CNR partd . c _ �°w 2115/04 PROPERTY AD ESS;700a S.-Main St. C on.f'anu1Lpo 17n-' 02632 On the above date,the�eptic system at the address above was inspected. This system consists of the following:. Pj 1. 1-1500 ga-P.Pon zept.ic tank:- 2. 1=d.istz.i�r�t.ion �ox. 3.• 3-330 ,zecha2geai.- Based on inspectlon, i certify the following conditions: 4.,7h.iz i.3 a t.it.Pe dive 3ept.ic hyhtem. (95code)., 5. 7he zept.ic byztem .i,3 .in paope2 wpak.ing oadea at the pnezent time. F SIGNATURE _ Name: Robert A. Paolini Company: Jtseh P. Mac mbar &Son Inc.—. Address: P. O. Box 66' Centerville, Mass 02632 Phone: 508-775.3338 or 508-77 - 4, ;lpSEPH P. MACOMBER & SON+.INC* Tanks►Cesspools-l.eachfields •Pumpgd .&•:Ins#eNed Town fewer•Conneqtlons P.O. Box 66 . Centerville, MA.02632-0066 -775-038 .' 775.6412- I , , COMMONWEALTH OF MASSACHUSETTS E+XECUT.M. -OPPICK OF ENV1R6VNMENTA�AFFAIRS DEPA2TMENT OF�+NV1�3,4I�f�"1`A3� PROTCTION R TITLE 5 OFFICIAL INSPECTION FORM_.NpT F -V-OLDISPOSAL* T1'RE1VI FORM SUBSURFACE,SEWAGE PART•A CERTIFICATION Property Address: 7 0 0 a Owner's Name: (PA.1_�1Li1sr Owner's Address: A rJ m a Date of Inspection: 12115101 Name of Inspector: (please print) Company Name: �.:�lac0M P—�t & . roe Inc. Mailing.Address: 0 2 6 3 2 en e2v c e, Cl.61 6. Telephone Number: 5 0-8-7 7 =3 3 3 CERTIFICATION STATEMENT . 1 certify that I have personally inspected the sewage disposal system,at this address and that'the.informatiou reported below is true;accurate and complete as of the time of the inspection.- lie inspection-was performed based on my training and experience in-the proper funetion and maintenance of on Bite sewage disposal systems.I am a DEP approved system inspector pursuant tto-Siction.15:3400110e 5(31.0 CMR,I15:400). Tile system: xzk Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving Authority &Fa* s Inspector's Signatare: i' Date:' .. o The system inspector shall submit a copy of this inspection ieport-to the-Approving Authority.(Board of Health or DEP)within 30 day.inspector and the system'owner.s s of completing this inspection.If the system:is.d.shaicid sy4tetn or has a design flow of 10,000 ter, the tiall`submit the'report to the appropriate regional office of the gpd or greater, DEP.The original should be sent tatha;system ovMmot W&Impios sontto tile buyer,if appiica6ie,and the approving authority. Notes and Comments ****Thls•report only describes conditions at the time of inspectift-andunder the conditions of use at-that thhe.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION,FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAtGE.DISPOSAL.SYSTEM INSPECTION.FOR'iV.I � PART A CERTIFICATION(continued) Property Address: 700a S.,Na-in Sl_ Cen t e2v i fie, Na., Owner: Le s.e.ie N ika e.eon Date of.Inspection: 12115104 Inspection Summary: Check A;B C,D or.E/ALW�AYSycbmpleWall 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: no One or more system components.as described in.the"Conditional Pass":section need to be replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. no . The septic tank is metal and over20 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 ifthe existing tank is replaced with'a complying septic tanlc.as approved by the:Board of Health. *A metal septic tank will pasi inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available.. ND explain: n o. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken;settled-or uneven distribution box.System will pass inspection-.if(with approval of Board of Health): broken.pipe(s)are replaced. . obstruction is removed distribution box is leveled or.replaced ND explain: Y no The system required pumping.more than 4 times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: ,2: I • Page 3 of 11 O1H'R'I4cIAL MPECTION FORM-'NOT VOR VOLUNTARY ASSESSMENTS SUggtTRFACE S W:A�GE DISROS*L SYSTEM INSPECTION FORM PART A_ 'C'ER.TIFPCA'RON(aontinued) : Property Address: 7 0 n rn !Mrz i n' S ranfonni Ua,lrin_ Owner:. I o A 0: Date of Inspection: C. Further Evaluation-is.Required by the Board of Health; no Conditions.exist which require fiuther..evaluation•by the•Brand:ofHealth;in•order.:tocdetertnine if-the system is failing to protect public•health, safety or the environment. 1. System will Vass unless Board-of Health determines�iu accordance with 310.CMR 15:303(1)(b)that the system is-not futetioning ilk.a•matniermhich mill.protect public health,safety•anO•the..envir-o tment: no Cesspool or privy is.within,50 feet of asurface water no Cesspool or privy is within 50 feet of•a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board-of Health(and Public Water Supplier,Af any),deteirmines that the system is functioning in a mariner, that protects thepttblic Health,safety and environment; no The system has a septic tank and soil absorption system-(SA•S).:and the SAS is within 100 feet.ofa surface water supply or-tributary to a.surface water.supply. R O The system-has-aseptic tank and SAS and the:SAS ivw•ithin a Zone 1 of a-.public watensupply. n o The system has a septic tank.and.tAS:and-the-SAS is within,50 feet of a private water.supply well. no The system has aseptic tank and SAS and the-SAS is less than 100 feet..but 50 feet or.:niore frorft 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 and volatile organic compounds indicates that the Well-is free from-pollution from.that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5.ppm,.provided that no other failure.criteria are triggered.'A copy of the analysis must be;attached to-this form. 3. Other; Page 4 of I I OFFIC AL•INSP.ECTiON FORM-NOT'FORVOLUNTARY ASSESSMENTS SUBSIJRFACE.SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART A CERTIFICATION, (continued) Property Address:7 0 0 a S ,Main LL Owner: [9'` o____- 42;4csje a*n Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate."yes".or"no"to.each.of-the:fo1lowirig:fbr all inspections: Yes No _ x Back-up of sewage:into-fadify.or system-'component due.to-overloaded:oi clogged$AS...or.cesspool _ z Discharge:or ponding of effluent to the.surface of the:.round or...surface maters due to an•overloaded or clogged SAS or cesspool _ x Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in-cesspool is less than.6"below invert or,available volume is less than'/S•day flow tructed pipe(s).Number x Required pumping more,than 4 times in the last year NOT due to clogged or obs of times pumped x Any portion of-the SAS,cesspool or privy is below high ground water elevation. Aiiy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion.:of a cesspool ror.privy is within :-Zone:1.,of a:public.well.. _ x Any portion of a cesspool or privy is within.50 feet of a private water supply well. _ x 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 coliform bacteria and volatile organic.compounds indicates:that the well is.free from pollutionjrom::tbat.facYlirty 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 attaehed.to this forte.] 2 0 (Yes/No)The system fails.I.have determined that one or.more:of:the:above.failure.•criteria exist as described in 310 CMR 15.303,therefore the.system.-fails.The system owner.should contact the Board of Health-to determine what will be-necessary to correct the failure. E. Large Systems: To be considered a large system the:systtm must.serve.a4aeility,with-a.design flow of 10,00.0 gpd'to 15i000. gpd• You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the-system is within 400 feet of a surface drinking-water supply x the system is within 206 feet of a tributary to a suffice drinking water supply x the:system is located In a nitrogen sensirivef 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. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOIL;VOLUNTARY ASSESSMENTS �1- )BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Cen�e2u.i.P_.Qe. (7a.• _ . I Owner: Date of Inspection: _ 9��9° �✓ Check if the following have been done You must indicate"yes"or"n0"as to each of the following: Yes No X — pumping information was provided'bythe owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as part of this inspection? Y x Were as built plans of the system*obtained and examined?(If they were not available tote as N/A) x Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site.? x _ 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? x _ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: Yes z _ Existing information.For example,a plan at the Board of.Health. " _ x 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTI:O}N::FOR1VM-NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE-S VAOE OISAOSA.L.-S.YSTtM INSPECTION FORM � PA RTI C SYSTEM INFORMATION Property Address: 700a S.,Na-i-n S-t.- Cente2vi,e,ee, Na., Owner: L .6,e P- Nikai,son Date of Inspection:_1 2/1 5/0 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.,,,,.3 Nwnber of.bedrooms..(actual): 2 DESIV flow-based on-310 CNM 15.201:(1or example:l I0 gpd x#df bedrooms): 1 9 0 x 2=2 2 0 y p d Number of current residents: .: Doesresidence have a garbage grinder(yes or no): no Is laundry on a separate sewage.system.(yes or.no):.n oo [if yes separate inspection required] Laundry system inspected(yes or no): t/,e.6 Seasonal use:(yes or no): n o Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no)y e h Last date of occupancy: /z,Z e h e n.t COMMERCIALM4bUSTRIAL Type of estabAli at: n a. Design s d on310 CMR 15.203):• „„ gP Basis.of doti.flow(seats/persons/sgft,etc.):, n Grease trappiesent(yes or no):.na � Industrial waste holding tank present(yes or no): n a Non-sanitary waste discharged to the Title 5 syste7m7(yes or no): Water-meter readings,if available: n a Last date of occupancy/use: . n a OTHER(describe):. GENERAL INFORMATION Pumping Records \ Source of information: .a.'!•'Naeom&e2 and zon Was system pumped as part of the inspection(yes or no):n o If yes,volume pumped: 15 0 0gallons--How was quantity pumped determined? m e a'3 u 2 e d Reason for.p-.umping: ma ri- a.in ce /'//22/Q 4 TYPE OF SYSTEM , xx Septic tank,distribution box,soil absorption system - _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank. —Attach a.copy of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1996 Were sewage odors detected when arriving at.the site(yes or no): no 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 700a S.-Main St.� CeatPay.i-tee, Ma.� Owner: I o,s Pip N i k a i z o n Date of Inspection:-Z/L 5/0 4 r BUILDING SEWER(locate on site plan) Depth below grade: 1 2" Materials of constructio t iron x 40 PVC_other(explain): Distance from private water supply well or suction line:-10' f Comments(on condition of joints,venting,evidence'of leakage,etc.): tit no evidence of .eeakage., Sy'6tem vented thorough house ven z., SEPTIC TANK: Ye locate on site plan) Depth below grade: 16" Material.of construction: x concrete metal fiberglass_polyethylene _other(explain) If tank is.metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a co of certificate) PY Dimensions:r0 Q o rz c113 '51"wide/5 ' 8"h.i gh Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: t 2 a c e Scum thickness:�_ • Distance from top of scum to top of outlet tee or baffle:_,,.0 m Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined-. m z-az si z e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,struct as related to outlet invert,evidence of leakage ural irate ,etc.): grits,liquid levels - -Ineet and outQet teen .in 12.Pace.,No evidence a� z tau ctuaa y noun GREASE TRAP: a oo(locate on site plan) Depth below grade: na Material of construction:_concrete—metal fiberglass--Polyethylene other (explain); — — Dimensions: na Scum thickness: --na Distance from top of scum to top of outlet tee or baffle:_ v Distance from bottom of scum to bottom of outlet tee or-baffl— ea:fL— Date of last pumping: n a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): 1'rih',liquid levels aeaze taap not /22e6ent.! Title S Tnonnntinn Fnrm�/1 ShMl1 7 Page 8 of 1 I OFFICIAL INS•FECTION FORM NOT FOR VOLUNTARY ASSESSMENTS :S- D`R:F'ACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Z(LDa .S.,P n-in St. (won I e yiLEP.Arl , Owner.. roAP!e g;kqPAnn Date of lbspection:-2/9 5/0 4 TIGHT or HOLDING TANK: no (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: na Material of construction: concrete metal fiberglass___polyethylene_other(explain): Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): na Alarm level: na Alarm in working order(yes or no):na Date of last pumping: na Comments(condition of alarm and float switches,etc.): 7i ght nn ho4d i ng .tank-3 not Bae6ent.- DISTRIBUTION BOX:ye'6 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no 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,): Box Hae one .Patenai.4o evidence o� 6o.ied,3 ca22yove2.' No evidence o,, .fie¢ age into oz but o7 Itox., PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no):na Alarms in working order(yes or no): na Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.); Pump ehamgez not, 122e,3ent.' _ 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 700a. S,,Na4n St., Owner:. /v.tl/lo l7Jk.��1/ tn2 Date of Inspection: 17 SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation not required) If SAS not located explain why: Located aee, a ce 10. Type. leaching pits,number: _ bleaching chambers,number: L 3 3 0 2e chaa yet, 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.): u : Ve et atIon [72 U hnad � .� o v n ol h a u CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: na Depth—top of liquid to inlet invert: na Depth of solids layer: na Depth of scum layer: na Dimensions of cesspool: na Materials of construction: na Indication of groundwater.inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ceh,3 oo �� not 2e�ent. PRIVY: no (locate on site plan) w Materials of construction. na Dimensions: na �. Depth of solids: na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 I Page 10 of 1-1 .0MC3iAL•YNSPEC3?•TQN-FORM-t NOT'FOR•'V•QLUNTARY ASSESSMENTS / SISSURFACRSEWAGE. oSAL SYSTEM•.INSFECTIOMFOR1V')r PARS'Cr SYSTEM 04FORA'ATIO`Pl1(conthiued)` Property. Address: 7 u a Aga n S t. . Owner. Date of Inspection: �n"/ SKETCH OF SE'WAGE•DISPOSA,L SYSTEM Provide'a sketch of the sewage disposal system includin&ties to at least two permanent reference l01tidrnarks or benchmarks.Locate gll wells within 100 feet.Locate where public•water supply enters.the building. 961. 10 i Page 11 of 1 I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSVSSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION(continued) Property Address: .700a S.,Ma-in Si,, Cente2y-i-eee. Na., Owner: LP A ' Date of Inspection: 1211 SITE EXAM Slope Surface water Check cellar. Shallow wells r.•j Estimated depth to ground water 0 feat Please indicate-(check)all methods used to determine the high ground water elevation: n o Obtained from system design plans on record-If checked,date of design plan rgviewed: e,Dbsorved site(abutting property/observation hole within 110 feet of,SAS) _ye 4hecked with local-Board of Health-explain: o 0. f a d n o rl. n A_o.„; o t c a t d' ram. ee jChecked:with local excavators,installers-(attach documentation) u,SAccessed USGS database=explain:httR:-town 9a2ri s.taUe.,ma.i u,6 �— You must describe how you established the high ground water elevation: used;Gaherty & Miller model 12/1b/94 ground w:at-Pr P1Pyai--Tnna, used;USGS observation well data june 1992 used; Technical bull wi er elevations. Q �J Groundwater: Feet Below Bottom- f Pit High Groundwater Adjustment 1.8 ft per YgimptejMethod-- Therefore,the.vertical•separation distance between the bottom of the lead ing pit and the adjusted groundwater table is feet: • tt . .*;la m t� TOWN OF BARNSTABLE : SEWAGE # " VII.LAJE C S ASSESSOR MAP&LOT5 INSTALLER'S NAME&PHONE NO.W YY) �e r SO n �I C✓ SEPTIC TANK CAPACITYoPCb 0 i< t 000 OM 6 C�441 he/- s LEACHING FACium (ty ) I A' -ed'S (size) Ia: S _ NO.OF BEDROOMS OR OWNER PERMITDATE:'�` l � COMPLIANCE DATE: leg-"" � 4 Separation Distance Between the: t Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le chin facility) D Feet Furnished by 1 � TOWN OF BARNSTABLE LOCATION 1904 5, n .SEWAGE if l6'-1jj<R VILLAGE ASSESSOR'S MAP & LOT/jj�'--6 7 INSTALLER'S NAME & PHONE NO, rniq� SEPTIC TANK CAPACITY LEACHING FACILITY:(type)�3_ e 4 ,cr NO. OF BEDROOMS®P. T =DL OR PUBLIC WATER HUILnpR OR oWN J��f,� 1�4cGll[ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 1' - �� ToWti OF Barnstable,e,.._ � T ''"-' 1 CTION FURM - PART D 11 •- GEII'f{`F�1ChT Si111g1111FACF SENAGF ()19f'U�aAWL ",YW M IISW— '�...'C1.1.T. ., •. W++ip.t OR P91N•1 GI.EMY- PROPERTY XNSP cnw STREET ADDRESS 700a S•'l�a�-n St' ASSESSORS MAP . 0[IOCK AND PARCEL # OWNER• ' s NAME Miku.Qzon PART D - CERT11' ' ATSON Ro geat P ao i ini NAME, OF INSPECTOR Inc . COMPANY NAME Joseph .P- Macomber • & `Son Box 6� Centeruille- Mass 02632 LY g(aty LIP COMPANY ADDRESS ---- 7o►m or strvvt FAX ( 508 ) 790-1.578 COMPANY TELEPHONE ( 508 ) 775-33-38 9911 Cf,R'PIFICAT-I0N. STATEMENT f that I... hsv.e personally inspected the sewa�Ccurate9aand11 ystem At I certify this address and that the inforenc o ,rTherinspectioneWas performed and any nt complete as of the time ofiinsp tions regarding u1=gr.ade'� maintennefunctionpand maintenztnceeof on 'recomrnenda experience in the proper with my' training and site sewage disposal systems . Check one ; xxx Systeoi .PASSED not found any , Ihich I have condu-c•.ted has Tie inspection tr adequately protect public which indicates that th-e system fails 03 , I I ealt11 or, the envir�onme" . as defined_ in the FAILURE 3CRITERIA f section o f criteria not evaluetted are as state ' this form . y � Sy Ste m FAILED* inspection which I have cond'Ctcted. has found that the system fails t The pect otsblic health and the environment in accordance with Title protectand as specifically Hated on PART C - FAILURE 5 , 310 CMR 15 , 3Q3 , CRITERIA of this insPectio for w ate,42 r Inspector Signature . this gKct•fication must be !Vrovided to the QWNL�R, the BUYER pine COPY of icabl®') and the p0ARD QF '( where app ,,�.. orator. ahe}.l cpgrado ' the Qyetem- * .If the inspection FAILED , oh' he i pe op .orator. within one year of the date oCr{Rhibi30p�ectiorr, unless allowed or reQpartd . d, otherwise as Provided in 3.10 i / ,, ,;- : -.: ,. r', t S ` ` } �`'h � i 4 :S;S\ Y St' �: 7 \ F N 1 '� ^c!St Yam. 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'--------____-------------------------- rb<EetlrRMItlYWEd.. ^• J DUD W.a N«Dm„Rr antl WY,tlowr IRI CU¢DES O w,l JrRrRD.=� THE GGLDENBERG HOUSE ® O - r. ..°NY,R<LRr.I 700 SOUTH MAIN STREET Rrrow mWro.'NtlRraM R«nouR RWwp tlee OSTERVILLE,MA aM CRppW RRafbrnLp mNr.N bnRw M,trw+ Rn w,b¢nRwtloo M°EICe�Stq ¢ eir.rbcoE°n br.bocbd W.n¢Ni TITLE One WNaR. FLOOR PLANS Pwoh SCALE:AS NOTED Emmo Ppcn Pad - ❑ O DATE Oaobc 5,2005 FIRST FLOOR PLAN DRAWN:cI xae:l/r n ra' SECOND FLOOR PLAN DRAWING NUMBER Scab:1/P a 1'11' D WISE,SLMMA-JONES-ARCNf1ECTS . beacon millwork 145 WIN . DOW Sa amore Beach MA 9 , 02562 Phone: 508 833-- 1921 43 LAUNDRY r pertY of Beacon Millwork rk Do not copy without permission 77 3 6 JCTERlQR DOOR FLOOR GRATE WINDOW WINDOW WINDOW WINDOW CLIENT I DESIGNER: CLOSET !� Shelves s Shelves ANNE MULLIN SERGESON t 416 MAIN ST APPLIANCE ATHAM,MA 508-348-0 3—DRAWER 3-DRAWER 3 DRAWER 3—DRAWER GARAGE 400 BASE g,q �, BASE BASE SE 26 BUILDER: IElm I CH NEWTON BUILDERS INC. 549 WEST FALMOUTH HWY 41 11 62 PANTRY WEST FALMOUTH,MA02574 73 CABINET 46 j 508-548-1353 E ; DISH- „ I_ 43 WASHER 48 508 (, `� I PROJECT MANAGER: 42" FAMILY ROOM JASON AINSWORTH � - - C: 508 982 6067 -_ KITCHEN A � 269�„ W1. THERMADOR STRUCTURAL ENGINEER: 117 „ 30» REFRIc - WEBB STRUCTURAL SERVICES ,, 32 » 670 MAIN ST 80 _ — READING,MA 01867 781-779-1330 Q / 1. � THERMADOR 24 INDOW _1 a D 18 FREEZE E Cu B 26 C � � Q 71" Clear Stof i ory Double W1. 49 J P W1. Above..' Trash 42j,t --- m CLOSET --- fi !� 43" , - -- 42" 60" 43" 25" �---! 213" 30" FLOOR GRATE WTERIOR - DOOR Wi. I I Ch nge to 1 �- ) F'renc oors zed' 25j„ ( Change to ! F OOR RATE /'� - French Door 33 ——— — — —— —— - 28" WINDOW WINDOW EXTERIOR 36" 38"——� —IMIR MUD ROOM 57H TOILET , FLOOR GRATE 38 I WINDOW • _ t17 Q F — LPLAFN SCALE. 1/2 If19 off ?00 S. MAIN ST z �^^ r N M Q 0— > > Uj Uj W Q Cr fy— Cy— 011 V) O w � ry Q m w wT- cn Z n o W Q 0_rr Uj m � r� mom O o o Q -� ¢ o' o JOB NUMBER: i DWG NO: MW1 . 1 t ASSESSORS REF. : ' ,' . • +, Map 186 ;. Parcels 037 4 1 1 •' ... - \ 1 ,y. .'i A'nor_ : .•�— q,- 3 � • OWNERS: 1 ' • �• William J Goldberg & 4 ,r '� r �•f Susan T. Nelligon ��. ate..t" 32 Wadsworth Lone Duxbury Moss., c. Nam• �t 11 r Il i �Y.Iw`�\ ''�`�'��Y 'oiehr�tiw; 'yr Wetland Resource tine V t rPxintedfmmTOPOIm1998;NildflowerProdnctions www.to o.com As Flagged by ENSR �� "9S i 9� 1► May 19, 2005. o�. REFERENCES: Locus Map _ Scale: 1 =2 OOOf \ It w m 9 CTF 175732 OVERLAY DISTRICT: AP — Aquifer Protection District Shown 1/ / / / ,- , / _ \ ��'► As own on Plan Entitled t h i. . \ led . / _6� \ / / ` �\, \ \\ ,� \\ \ "Revised Groundwater Protection ' q,2� �`\ / // // // / J _ — \ \\ \\ \ \ •IN.\ Overlay Districts — April, 1993 50, / \ \ \ 1 \ \\ �• ZONE / \ l Area (min.) 87, 120 SF (RPOD) I �\ q,3 ! \ \ , \ \ Frontage min 20 L_e E:n , _ Width • 1 1 \ / / � � l / .-�,.,.-' ! �� �,� /�• �\ ~' \ \ \ � �t ~`moo \\ \\ � (min) 125' , I:__.�_� Light Post �� / I_..., (9. ....50,...eu`ii __. ._.__.. 1 `` I o/ / / �•�•• / \\ �'�\\ \\ \\ tl \ \ \ \\ � \ Setbacks: f P Wetland Flag 1 / / Fron t 30 Side 10' Gas Gate p Water Gate / \ \ 1 Rear. .10 Q Misc Manholeool ` ® Drain I 1 , Pfgot41 Hydrant �,R P, I 1 , + ,' l - / \ \\ �� \ \ \ FLOOD ZONE. I O Iron Pipe \ \ \ \ \ \ ElCB DH — Concrete Bound w Drill Hole Zone B, C, & A10 (el 11) / / o SB/DH — Stone Bound ' ' ' I I `� 1 I ++ 1 / �ti;� ' / / ,.,r'\\/ \ \ \ \ `t \ \ \ \ \ Community Panel No. Mu magnail 11 ' II 1 `�I \ i `\ �\1 I /;�Q,�,•� /! // //, o {t`` / � �, \ FED\Zone B \\ \\ \ \\ \ 11250001 0016D J -o Y I .' �.' / 10 e / 1\ } \ \ \ \ \ July 2, 1992 J- Utility Pole 1 \\`+ I I \ o`� I l� ^� ,.•; 1 { ... � N --�� \ \ \ \ Ho.,diib Deciduous Tree O _ / ! \_ •-! 1 \Approx ,� - I \ 1 1 \ P+ t ( I I " / ., saptic o µCS I \ \ �\ `tl \ \ \ \ I t I e systam m 1 (by TOB)96-168 Coniferous Tree peekco J �\ \ \ \ \ \ \ \ \ \ m \\ \ Prapk� } �'•.. \ I \ I I I I FEMA Zone Lines Holly Tree / \ \ \ + \ t + \ \ \ \ ran .,� } 1 I / \ \ �• \` \ \ \ \ ppoe I 1 + I I � I As Shown on FIRM \ t t \ \ sty w# l I Panel # 250001 0016 D �'\ \I \\ \ \ \ \\ \ t cottage I / / �`I / 1 rev July 2, 1992 /1 1 1 Shy l ° Garage t I s \ \ ` / / / ^ � Payed / .. _ -.-- \. - •2n1 _ t lJ P,-- Lawn \ \ 1- i /It I Wetland Area s �3� / °b Lawn w n 1 ` / `...•�.J I I \ Lawn / ' 1 • —► � �o O) 1 � idf v t Cr I .— Cover #6BZW�1 \x^? \ 11 I I �itd` I \ 2p tYtlng tt to Septic S Coe ak vat ermt/ /`7�.• .! / t l \ \ .. 96-169 / 1 9A. IEn1 \ \1 I I /Lawn% Patio, N \ (by TOB) / ; m 1 Stoll e \ 0 \ / t �0 2 p dj O I \ -• StsP' ton +: I lawn / a t Rgt p`Chttects - \ W"� Parcel 1 / I I �` ' or interior viise Surma ' 0-, I 9y Nfisa 0A / Poke \ \ Area l z r� 102,494-+SF 2.35±Acres Upland 1 i / a 'i ` sty+tlt ° o E 47,934±SF 1.10±Acres Wetland 9 2 Dwel11n9 Q 150,428±SF 3.45±Acres Total >CL 1 \ \ I I ' }penis .•\ \ � �tl' � 1 Law. - 1 h�\ Z Sty 0 •� t yard SOtb NIt 1 ` 9 / --�30, fro^ . / thd • South Main / '` �' '-� Lawn — — SlBit 10, =t , Overview yl / I \ ___�_ / / Q Grote Ng2',a�� h f� ' Pays � lawn �O7 — ' / edge a e \\ tr h { Bit Sidewalk a _ L outs _ \ aY ye 1919 St NGVD g4.3! o,,,,.-- state N;ghwoY � ••� �' \ �1 a ,4a Ed9e o,Pa h �10 N407+ "F , wide _. (4p i LCB so _ /nd _ of Pave h � 1 • � t ,gyp;�+a5��-��q{�'�-` � A, ot. 5 1 €.Q.2-0733 o 1 CIVIL��i Vic. TITLE: PREPARED BY- PREPARED FOR: OTES/REVISIONS 1 Proposed Plan of Improvements CapeSumr, 1.) The property line information shown wasSullivan Engineering, Inc. 1 At 700 South Main Street I compiled from available record information. PO Box 659 7 Parker Rood C. l-f.- ,Newton-,., Builders,_. Inc.- .__. .___._- . Osferviile; MA 02655 _ Osterville MA 0265�1 " 2.) The topographic information was obtained from Barnstable (Centerville) MASS. 919 Main Street (508)428-3344 (508)428-3115 fax (508)420-3994 (508)420-3995 fax on on—the—ground survey performed by CapeSury PSuIIPE(§bol.com capesurvik-apecod.net Osterville MA 02655on or between 08/JUN/05 and 01/JUL/05. W L.I r DWB J.) The datum used is NGVD '29, a fixed mean Draft: Feld: WHK/JPM 20 0 10 20 40 80 sea level datum. DATE: SCALE: rr r Comp/Review: JOD/PS Comp/Draft: WHK/RRL 1— OCT 14 2005 =2O 25021 Drawing # C492_1 1 Proj. REV 1 — 201SEP105 — additional wetland flags west. ,# � _j }