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HomeMy WebLinkAbout0772 SOUTH MAIN STREET - Health 772 South Main Street Centerville A= 185-009 S M E A D No.2.153LOR UPC 125U smsad.com • Made In USA -4-V O1m um M D/DUCT in IF ��PWOM wo Rogow&= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 1 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service y Company Name 17 Playground Lane Company Address Yarmouthport Ma 02675 Cityrrown State Zip Code 508 362-3555 S14454 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: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/1/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report.only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. inn t5ins-11/10 Title 5 Official Inspection Form: ubs ce Sewage Disposal System•Page 1 of 17 ' f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 772 So. Main St. ,p - Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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. Systefn 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 El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within . 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ © Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow t5ins•11/10` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments "Y 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 611/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ N Required pumping more than 4 times.in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a 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 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no as to each of the following: Yes No ❑x ❑ Pumping information was provided by the 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? Z ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ 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? 0 ❑ 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: ❑ ❑x Existing information. For example, a plan at the Board of Health. ❑ 0 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5irr•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is Centerville Ma. 02632 611/12 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 No. Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? O Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes 0 No Last date of occupancy: 6/1/12 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? J ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Robert Paolini Septic Service Was system pumped as part of the inspection? 0 Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? measured Reason for pumping: maintenance Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes R No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the Building vents. Septic Tank(locate on site plan): Depth below grade: 2' feet Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 16" t5ins•11f10 Title 5 Official Inspection Form:Subsurface Sewage l3isposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r 772 So. Main St. Property Address Claire Fraser Owner owner's Name information is Centerville Ma. 02632 6/1/12 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 18" Scum thickness 2" 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.Inlet and outlet tees are in place.No evidence of leakage.Tank appears structurally sound. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser owner owner's Name information is required for every Centerville Ma. 02632 6/1/12 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.): 0 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 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 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 is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ` Sandy dry soil.No signs of hydraulic failure.Both pits were dry at time of inspection.Pit#1 stain line was 5' below invet.Pit#2 stain line was 4' below invert. 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•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 J Commonwealth of Massachusetts T. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection D: System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•11110 1 Map http://66.203.95.236/arcims/appgeoapp/map.aspx?property]D=1850... Town of Barnstable Geographic Information System Parcel Viewer Custom Map utters7 Map Size 0l m Zoom Out O O O O®O Q o Q In J 31 t o V 4 �A N �rA a 'i •NS 4•'p bj{i ••i i a ;20 eet • e Set Scale 1" = 20 i Aerial Photos MAP DISCLAIMER 1 of 2 6/6/2012 9:42 AM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owners Name information is required for every Centerville Ma. 02632 6/1/12 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Fx� Surface water 0 Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Leaching 7' 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) M Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 annual ranges of ground water elevations. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 772 So. Main St. Property Address Claire Fraser Owner Owner's Name information is required for every Centerville Ma. 02632 6/1/12 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I f5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i COMMONWEALTH OF MASSACHUSETTS T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y d DEPARTMENT OF ENVIRONMENTAL PROTECTION i q's c � SAP i�qM SVev� � /� 350 MAIN STREET PARCEL U A WEST YARMOUTH,MA LOT 1_— �O 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 185 PAR 009 Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner's Name: JONES,GEORGE na -=1 Owner's Address: 772 SOUTH MAIN STREET O CENTERVILLE,MA 02632 Date of Inspection MARCH 22,2004 Name of Inspector:(please print) JAMES D. SEARS N 7> Company Name: A&B Canco O Mailing Address: 350 Main Street N West Yarmouth,MA 02673 � Telephone Number: 508-775-2800 ry a) vt r— rn CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within.30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 C. Further Evaluation is Required by the Board of Health: N/A 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. system is not funrtiol6pgt6maKdiPaer WHwh gotlg*ofeitepUW&eberItines at3nam hmenviiiinAidiCMR 15.303(1)(b)that the Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pits is less than 6"below invert or available volume is less than %z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 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 No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] I Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002 164,000/2003 123,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: N/A Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 BUILDING SEWER(locate on site plan): ./ Depth below grade: 12" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ./ Depth below grade: 2' Material of construction: concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" 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: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.INLET TEE,OUTLET TEE.COVER AT 8".NO SIGN OF OVERLOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): 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.,): DISTRIBUTION BOX IS 16"xl6",T BELOW GRADE.ONE LINE IN,TWO LINES OUT.BOX IS CLEAN AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 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: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS TWO 1,000 GALLON H-20 PRE CAST PITS.PITS ARE IN DRIVEWAY.PITS ARE 2'BELOW GRADE WITH BOTH COVERS 2' STEEL AT GRADE. 18"WATER IN PITS.STAIN LINE AT 2'.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 F'aee 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 772 SOUTH MAIN STREET CENTERVILLE,MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. _7�,x J � 33 U Title 5 Inspection Form 6/15/2000 10 Page 1 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 772 SOUTH MAIN STREET CEN T:=,KVILLE_MA 02632 Owner: JONES,GEORGE Date of Inspection: MARCH 22,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: TEST HOLE 12'NO WATER.BOTTOM OF PIT 8' BELOW GRADE.BOTTOM OF PIT 4' ABOVE TEST HOLE. y C, flt f �T 4 I Title 5 Inspection Form 6/15/2000 11 TOWN OF BARN TABLE 1,0CATION SEWAGE # _ `:�II,LAGE ASSESSOR'S MAP & LOT T45AVV--0S: NAME&PHONE NO. SEPTIC TANK CAPACITY . LEACHING FACILITY:.(type) (size)ZO& &ea ,6 . NO.OF BEDROOMS BUILDER O OWNE , PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I �j1 10 j O 3 l� �3i,&„ TOWN OF BARNSTABLE . OCATION S SEWAGE # -VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �U r�/�'li"C 0 SEPTIC TANK CAPACITY / ti ,S /4— � L- 0 LEACHING FACILITY: (type) (size) NO,OF BEDROOMS _ BUILDER OR OWNER URMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ,o 33_� zJ� No. r) I Fee Sp THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for M.5 pozat bpttem ConMruction Permit Application for a Permit to Construct( )Repair(XUpgrade( )Abandon( ) El Complete System dividual Components Location Address or Lot No./17 n S 0 I, 1j fA 5 7— Ow�n+er's Name,Address and Tel.No. Assessor's Map/Parcel o` C. L tiT P O S-9o9 9 9 s® M��,� s�' C f•L� Installer's Name,Address,and Tel.No..5—4 T-7/)5- Designer's Name,Address and Tel.No. 14 f16 0A55-0 NC Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)' °V 0 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 is d by this Board of Health. Signed Date �Mr�3' a,koo' Application Approved by /P I Date Application Disapproved for th ollowing reasons Permit No. QWoL4'/a) Date Issued 3'��-0 V y No. t)d `� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPrication for Mi5vonl 6potem Construction Permit Application for a Permit to Construct,( )Re air(Upgrade Abandon p ( )Abandon( ) El Complete System 9'Individual Components. 4 Location Address or Lot No. 79 S 0 �,41ti 5 7— Owner's Name,Address and Tel.No. Assessor's Map/Parcel C g tiT G £oleo Installer's Name,Address,and Tel.No. .5-6 3'-7 1? p0 0 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( )`Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size'of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) / A" S14 L L p y T - F 7 �£ 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 issrt d by this Board of Health.Signed y. �.— - ..'Date L o2i 3- ' f/�` Application Approved by �.�., i� s Date Application Disapproved for the ollowing reasons Permit No. as vy Date Issued --------------------------------------- T-,5wl 0-uej k-r- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comviiance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ,(—)-Upgraded( ) Abandoned( )by A /R OX A,' ('O 3 s i /r at 7 7 -SO W4/,u 5 7- (.v- - W/f has been constructed in accordance with the pr i sions of Title 5 and the for Disposal System Construction Permit No. Do dated V Installer Designer The issue ce f this permit shall not be construed as a guarantee that the sy em wi�l�functi as d��gned. Date Z�� u L/ Inspector ,�, No. -2 U o U Q- I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mocoar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( 4-)-Upgrade( )Abandon( ) System located at 7 9 s 7- 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. Provided:Constructi76L must be completed within three years of the date of ttn's-permi . Date: !, 3l Approved pb OA) Y � _ • S P ., t '�M1 v ; u 3'. `k' ,5 J ..P•s -'1af g+r;{'ii. _ "1'., x r i.0 .w: � - :: ,�•,�;;*',`w.� t' '�1 ".*,ya 'Gt'a .'ip� E},,�,t-fff p� ry ..?v. ,. ' :,t �4i r'+S,xr,§' e�7 r1r.:3�:r�.' t�/',"phi " °'fit,t'f.. � 5' ',y ,}ec yy _n, ,.�''• � ...�r�,y: ` s y-•: -a`1.3f t+ ,,"�+ �4'`;kY.r •£p.,. f I BORTOLOTTI CONSTRUCTION,INC. 00RPV&*,,v ' 765 WAKEBY ROAD,MARSTONS MILLS,MA 0264508-771-9399 509 428-8926 FAX: 5014 4289399SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSPECTIOPART ACERTIFICATIONProperty Address: �� Date of Inspection: a 6 Inspector's Name: i er's Name d Address , C) 3- CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal sy4ems. The System: _/Passes Conditionally Passes Needs Further Eval on B the Local Aproving Authority Fails Inspector's Signature: ���' Date:�� 17 g r The System Inspector shall submit a copy of this inspection report to the Approving authority widdn thir- ty(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 shale submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: A)SYSTF*PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - Y '{ x"i. -a}{ "-a T���?7°yt3 12��#�'�.,. S-,a,,.: '.."`,.r,, .`.Ii,-._e,'. - � ,^: d ? •r5� ��w } �� y3 yn'.�y� ,t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed lw Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLICAEALTH AND SAFETY AND THE , ENVIRONMENT:. . The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply.. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has aseptic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution`from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. _ D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health. should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the.distribu{ion box above outlet invert due to an overloaded or clog- ged SAS oucesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow: Required pumping more than 4 times in the last year NDI due to clogged or obstructed pipe(s). Number of times pumped -2- �`"5+�`;..�'^��.; .•'7yr" �=4a .,*. .+.'.,��' ky.. .7`t 'a�'° (!•.f h;u K ... h4.,+'c^ ,n � ` x ' t y ,, �.u a 4o- t ' <4. .a ,�.. ,.. � ... .... �'w��as�'�i�n.•..t�'. .t,.�"R'-.k`*r{' �r., � .. _ ,' F f", .K' ,�„a�`'1; 'o x�' ,�F r��' '4j9k ,.,.rµ: i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within.50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 Il of a public water supply well. ' The owner or operator of any such system shall bring the system and facility into full compliance`with the groundwater treatment program requirements of 314 CMR.5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: 1-`�Pumping information was requested of the owner,occupant,and Board of Health. !/ None of the system components have been pumped for aticast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note ii'they are not available with N/A. v"The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste Dow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened;and the,interior of the septic tank was in- s ed for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- i So NO Kagl,�41� F I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) v The facility owner(and occupants, if different front owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS 7Garbage w: Ions Number of Bedrooms: Number of Current Residents: rinder: Laundry Connected To System:� Seasonal Use:er Readi s, ' vailable: Last Date of Occupan COMMERCLAIJINDUSTRIAL: Type of Establishment: Design Flow: Qallons/day' Grease Trap Present:(yes.or no) Industrial Waste Holding Tank Present: . Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 17h,2 System Pumped as part of inspection: If yes,volume'pumped: gallons Reason for pumping: TYPE F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of al components,date installed(if kno n)`and source of information: Sewage odors detected when arriving at the site I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grad Material of Construction:—concrete—metal—FRP—Other (explain)Dimisions:IV,6"Y(PT 1 Sludge Depth: N Scum'rhickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:__1zz_1_ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 el in at on t o et invert,structural integri�y,evidence of leakage,et�pq. 77a 121frl)L/I A .1i a .6 GREASE TRAP: Depth Below Grade: Material of Constructiow—coticrete metal—FRP—Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: -.-Comments: (recommendation for.pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity;evi,dence of leakage,'etc.)_ TIGHT OR HOLDING TANK:'do Depth Below Grade: Material of Constructioit:—concrule—metal_FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallonsiday Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Aat'l van V s carryover,evidence a Comments: (note if I el and distribution is.0 vid c of solid idence of leak to or out o box etc PUMP tFLAMBER:,A Pump is in working order: ind'appurtenances, Comments: (note condition of pump chamber,condition of pumps, etc.)_ q ,. yip 1Y.e . d ,:iyg h'1 Y�✓ ��q ,'k _ ? Y' w�r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive ° methods) If not determined to be present,explain: t .Type Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition of s il,signs of by aulic failure level of nding,co iUion of vegetation, e .) _' A CESSPOOLS: -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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: U Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - ,� �`.==b >�. E+ R` "*.a 'hr'._. `•.`� ''..� s w,R'.s'�t� �'...:,3e„�.:. ,E; 3 .s `t'" a. "'. ,a,d fi x ,a it' 'u a.... r w�,,+ i 0 # �`a;•' RPM��Y� �s��Y,` �� ���"��� to .+~7,�FM, ., ��� �-�• '�`,.�;o-,,+^� :4xq+f� � � S• t rt �r: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: IInclude ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. O' 31 ILI DEPTH TO GROUNDWATER: J Depth to groundwater: Feet Method of Determination or A pro 'matio r: -7- � . ac ' Complete-Septic-Service We Design-install b Service 350 Main St. West Yarmouth,MA 02673 1 Since 1931 Phone(508)775-2800 l �� 36%yJ,SEPTIC EVALUATION LOCATIONt a ¢/•� Sr DATE: csti7- TOs V JAI G£iC'�NIoTS 7 f2A S ?VfIN 57— C t Nr The septic system at the above stated location was evaluated by A & B Canco on 1995 The system is located front rear/le ft/r'igh of the dwelling and consists oft soa G w 1711 sT.rr c All connections of the system are made with k- C- The system is i SATISFACT'OFYIUNSATISFACTORY condition at this tithe.. It doe meet the rF.quirements of the State Environuenfal"Cod'e. Title 5s Minimum Requirements for the'Subs'brface Disposal of Sanitary Sewage. Check if applicable [ ]However, it is 41lowable under current board of health regulations until its failure. NOTEt A do B Canco has had no control over the use and/or routine maintenance of the septic system. Circumstances such as a recent pumping will significantly alter evaluation results. No guarantee or warranty is hereby given, express or implied, as to the evaluation. If you have any questions. please call me at 508-775-6264 between 8t30 am and 4s30 pm. Monday through Friday. Sincerely. Septic Inspector i SEPTIC EVALUATION 7* INTAKE• DATE OF ORDER: 3 /a?/5S ORDER TAKEN BY: / PROPERTY TO BE EVALUATED: MAILING ADDRESS: NAME: �2)Dq� VIl ti Cr y41ivy NAME: STREET: 7 7a .Se ,�i/gl, si STREET: TOWN: C£ti7— TOWN: TELEPHONE: ( ) TELEPHONE: ( ) LOCATION OF SYSTEM: PIPING: PV [ J CONDITION OF PIPING: �oo� ORANGEBURG [ ] CLAY CAST IRON [ ] TANKS) CESSPOOLS(S) : - NUMBER SIZE /,S'.-v BLOCK [ ]: CONDIT4+ION OF TANK: PRECAST [ ) I [ J LEACHING PITS [ ] NUMLI.,ER VOL CESSPOOL [ ] NUMBER VOL ,u o GALLEYS [ ) CONDITION OF LEACHING DIFFUSERS FIELD [ ] c OTHER. [ ] :DESCRIBE: ___ CONDITION OF SYSTEM: GOOD: [,,r] EVALUATION COMMENTS: POOR: [ ] FAILED: [ ] DATE SYSTEM INSTALLED OR AGE OF SYSTEM: SYSTEM HAS BEEN MAINTAINED? YES [ ) NO [ ] UNKNOWN [k] SYSTEM HAS BEEN REGtIA-hY PUMPED YES [ ] NO [ ] UNKNOWN [k] WHEN WAS SYSTEM LAST PUMPED? SYSTEM MEETS TITLE . 5 CODE? YES [), ] NO [ ] UNKNOWN [ ] *******************SKETCH OF SYSTEM**************** . I j too n0 0 7 4 TOWN OF BARNSTABLE LOCATION 7'7R SWAGE # VILLAGE � � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS Pam:TE :':,FOR PUBLIC WATER BUI:L-EMR- OR OWNER , &,gf- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No `C,ALOCATION S SEWAGE PERMIT NO. 3/3 -7 'ILLAGE I N S T A ER'S NAME i AD R E S S < d i 9 U I L D E R OR OWNER DATE PERMIT4 ISSUED DATE COMPLIANCE ISSUED - f w i {����� . �/� . ��_ S� �/ ._`. ��` � � � ��e , � � -� � ,�-� �, a,- r. . , i, _ F _ , �, ,,,�4F�„1 . � ��, •' .I ,\ r � �.` 4. y � .i A. �J� THE COMMONWEALTH OF MASSACHUSETTS ,-. BOAR® QF /HEALTH �O11�).......oF......•! l��d� �c�'�/- ...._.. Appliratina' for DinpnnFal Vorko Tnnitrnrtinn ranfit Application is hereby made for ai Permit to Construct ( ) or Repair ( Wan Individual Sewage Disposal Sys ostem at: ' - . . ..........:.................... ..... - �...__. ( cation-Address or Lot No. wr ------......•...................Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling o. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons-----_-________:-._---_---__ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..........-..... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) IDosing tank ( ) Percolation Test Results Performed by.......................................................................... Date_................. ----------------- . Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-____-_-_--------------. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------- ----------------------------------------------------------------------•------------------------------------------.............. .. 0 Description of Soil------.. -•-------•-------------•-------------------•--------------------------------------------------------------------------------r-------•--- x W ------------------------------------------------------------------------------------------------- --------- - ---- U Nature of Repairs or Alterations—Answer when applicable- �� �... :.......................................................... -•-------------------------------------------------•----•---....---•-----------------.......-------------..a.—A i� � ............-..................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT 1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by eVrd /41 Signe `= --....-- --•- ... a �- Date Application Approved B ... . ..................... Date Application Disapproved for the following reasons-----------------------.----------------------------------------------------------------••---------------- . ...........................•-•---•-•----......_..------------...-..------•--------....--........--------•..---------------------------------------------------------------------------------------•_•.... �5 -� Date Permit No----------------•---........:._..�_1_..--•----------- Date Permit ' Date N ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r . / .s ............../`. ...'��,wf,,.r........OF......::•� J..rsrf,..��?...;''',_^. ,,i <..r:°............................. Allp iration for Disposal Works Tontrurtion .emit 1. Application is hereby made for a Permit to Construct ( ) or Repair ( 4ran Individual Sewage Disposal System at � ;y Isoration-Address or Lot No. £ r 9 Owner ....----• -•--••-----•---•----••-------------- .------- � r � Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling . No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—TYPe of Building ---------•-----------•--•--• No. of persons............................ Showers Cafeteria Otherfixtures -----------•---------------------•-----•--------------...-----------------------------...-------------------------•----•. -(----)- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No...............:..... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_-___-.---._.--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........•............................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-._-_---___-__:_---_-_-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •----------•--•----------------------------------------------------------------- O Description of Soil....... :%i=`.-! .______________ x ...................•-•••-•------••••---••-•-••-•••----•----•••••-••----•----....•-••---••-••......•---•................ V ...••--•-•--••-•--•--------•••••----•••.....-••--•---------••-•---••--•---------•..................••......--•••--•---•-•--••--•--•----••--•------••••-•••••----•---••-••-•••----••--••-.._......--•--•-- w ••-•-•-----------------------•-•••-------------••••-----•-----------•---•---•-•••••--•-•-•............--•-•••• =------�.,- --------r U P PP `: o ..` -_..."�s��,;1. ---------------------------------------•----.. Nature of Repairs or Alterations—Answer when a hcable_ _�........:.... f=��<_ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT ILj. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health / Signed ......................../_J; 111 - r Date Application Approved BY .c � ':.. :.. �1� vYer� =---=----------••-------- // -t� l 0 Date Application Disapproved for the following reasons---------------•-------------••--••---------•------------------•------------------------•--......--•--------•---- ..............•-----•-----......--------......--•-•-•---------....---........----•--------•--------------•------•----•-------•---•--•-•---.•-••-------•••••-••--••---••-••. ............................ Date Permit No.-------- {`-°. .�,-'s ................ Issued....................................................... Date TH'E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e ,x ............... ' `c•.........O F................ ..........>.....:..........:............:.....c:.................... kfrrtifiratr of Tontpfiatta TEU.St19 TO�,CERTIFY, That the Individual-Sewage Disp.sad System constructed ( ) or Repaired (�.}K y -� >r / Installers / °e" d { 1 �: ram .., r 6 .o .. " , at_•...... _.. k.......•........' -`--......: . .------......�-_.. ....._.. ..... . � " ---_-•. . ✓d. � c � has been installed in accordance with the provisions of TITLE 5 of TILe State Sanitary Code a,esc in the application for Disposal Works Construction Permit No.........."�, _y................. dated_...._.__ ' _..__ ._......_._.._._. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CO TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ION SATISFACTORY. DATE........................6- .t. q-fie---.......................... Inspector.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No............... � FEE. _......... Dismal orkii �onitruction .er- tit r, ,� ,:•. Permission is hereby granted l.........................r_._AA/:�CQ:IEI j �' ..w_ "_... " - �-� to Construcx (y or Repair ( -) an IndividualrSewage Disposal rr te> t . Street As shown on the application for Disposal Works Construction Permit No. =---�----� Dated....... '�`� /•• ........... t , :?e�.. r " «T Board of Health $ MATE l`� •---------••......•------------------- . FORM, 1255 A. M. SULKIN;.INC.. BOSTON