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HomeMy WebLinkAbout0002 SOUTH PRECINCT ROAD - Health 2-South Precinct Road Centerville P A = 148 137 No. 42101/3 ®RA Pondo, ©TIMWC� 1000 \ A O 0 Commonwealth of Massachusetts ` - p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name / information is Centerville ✓ Ma 11/6/2020 required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. Inspector Information on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. r� Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 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 t 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 11/6/2020 Inspector's S' ature Date The system inspector sh submit a y of this inspection report to the Approving Authority(Board of Health or DEP)within o 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown 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: ® 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal,coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to.or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 ' Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? W® El Was the site inspected for signs of break out. E ❑ 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 ' Commonwealth of Massachusetts n - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): on design Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 6'x6'precast pit with 2'stone Number of current residents: 3 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: gimped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: due for maint. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c .� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Citylrown 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 j 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: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5' 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.): no signs of leaks or poor venting t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal. H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 14" Distance from top of sludge to bottom of outlet tee or baffle 16" Scum thickness 4„ Distance from top of scum to top of outlet tee or baffle 311 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? tape and 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.): baffles in place. no major decay present. no visable leaks. pump tank every 2 years under normal use t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts ,1 Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville J Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *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.): Dbox was camera inspected and appears newer then system. no major decay or caqy overs t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .• 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection D. System. Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit cover dug up. current water level is 17" below invert pipe. no staining over current level 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.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/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.): J 4 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 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 %` O 15insp.doc•rev.7126/2018 a 181e 5 Official Inspection Fortin Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 2 South Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 16' 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: lot el. 50 low area wetlands behind property el. 34' bottom of SAS el. 40' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 South Precinct Rd Property Address Tasha Ramos Owner Owners Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �.� 24recinct Rd Property Address Tasha Ramos r Owner Owner's Name inormation is Centerville requiredforevery Ma 11/6/2020 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. Inspector Information # /6'05(® filling out forms p �� on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. . VQ P.O.Box 151 � Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 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 1/6/2020 I Signature Date The system insp r shall submit a c of this in pection report to the Approving Authority(Board of Health or DE )within 30 days completing s inspection. If the system has a design flow of 10,000 gpd or greater, the in ctor and th stem owner shall submit the report to the appropriate regional office of the DEP. T orm 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ./ I� u 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. j Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass ov i 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coat.) ❑ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required wired for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (coat.) 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): no design Number of bedrooms (actual): 3 on file DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 6'x6' precast pit with 2'stone Number of current residents: 3 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name required for is every Centerville required Ma 11/6/2020 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(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: pumped during inspection Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: due for maint. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 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: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5' 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.): no signs of leaks or poor venting t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts - ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): ' Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal. H 10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No .Dimensions: 8'x5' Sludge depth: 14" Distance from top of sludge to bottom of outlet tee or baffle 16" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? tape and 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.): baffles in place. no major decay present. no visable leaks pump tank every 2 years under normal use t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dbox was camera inspected and appears newer then system no major decay or car overs t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts fn ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit cover dug up. current water level is 17" below invert pipe no staining over current level 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Cityrrown 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts 1 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Precinct Rd .Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. . Citylrown 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 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 16 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked date of reviewed: plan design g p e ed. 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: lot el. 50 low area wetlands behind property el. 34' bottom of SAS el 40' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 s Commonwealth of Massachusetts - ig Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2 Precinct Rd Property Address Tasha Ramos Owner Owner's Name information is required for every Centerville Ma 11/6/2020 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 _ SZ COMMONWEALTH OF K-kSSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION J' 1�-C ` 1?pp7 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2 SOUTH PRECINCT STREET CENTERVILLE Owner's Name: STANLEY KECTIC Owner's Address: C/O JACLYN SANBORN 374 CAIRN RIDGE ROAD, EAST FALMOUTH MA 02536 Date of Inspection: DECEMBER 12.2001 (L � 11AP� Name of Inspector: (please print) JAMES A. ORPHANOS r�� Company Name: CERTIFIED INSPECTION 1 4A Mailing Address: 47 CAMERON ROAD NORTH FALMOUTH, MA 02556 Telephone Number:' (508)564-5653 ' '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 15.00). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's SigGinsantd Date: DECEMBER I5, 20U1 The system inspect it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 daeing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the 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. Notes and Comments The inspection is not designed to determine the remaining life expectancy,of the sewage disposal system. . Buyers are urged to consult further with an environmental engineer about any part of the inspection they do nof understand. ' j - ****This report only describes conditions at the time of the inspection and under the conditions of use at that time. Tliis 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 page 1 Page 2 of 1 I ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CNIR 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. 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 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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pi.pe(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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION-(coni nuM) Property Address: 2 SOUTH PRECINCT ROAD _ Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12. 2001 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 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 wetlandor a 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 the environment: The system has a septic tank and'soilabsorption system(SAS) and the-SAS is wrttiin'l00 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen i;equal to or less than 5 pprn, providedthat no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 II Page 4 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12,2001 D. System Failure Criteria applicable to all systems: you must indicate "yes" or"no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due town overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 the high groundwater elevation. X Any 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 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 duality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliforrn 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 forma 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either "yes" or"no" as 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 I1 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a 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 1 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B. CHECKLIST Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12,2001 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 requested of the owner, occupant, or Board of Health. X Were any of the system,components purr.ped out in the previous two weeks X _ Has the system received normal flows in the previous two weeks? X Have large volumes of water been introduced to the system recently or as part of this inspection ? N/A 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 breakout ? Were all system components, excluding the SAS located on site `�1 ." r. .: ^tom-•.."',. . •t. •:.,,' r ,}. .. ' r' ': X Were the septic tank manholes uncovered opened, and the interior of the septic 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 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 CM 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KE TI Date of Inspection: DECEMBER 12,2001 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x of bedrooms): 330 GPD Number of current residents: 0 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): N/A Seasonal use(yes or no): NO Water meter readings, if available(last 2 year usage(gpd): 1999/2000 is 30 000& 1 000 gallons• 2001 iN 0 gallons Sump Pump (yes or no): NONE OBSERVED Last date of occupancy: JANUARY 2001 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow: (based on 310 CNIR 15,203) Basis of design flow(seat s/person/sgft,etc.): Grease trap present (yes or no)i 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: NONE, ACCORDING TO JACLYN SANBORN Was system,pumped as part of inspection (yes or no): NO If yes, volume pumped:_ gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x X 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 the 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:.... - Were sewage odors detected when arriving at the site (yes or no): NO 6 Page 7 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 2 SOUTH PRECINCT ROAD ,`•;b_ Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12,2001 BUILDING SEWER(locate on site plan) N/A Depth below grade: Material 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 on site plan) X Depth below grade: 14" Material of construction: X concrete metal Fiberglass Polyethylene other(explain) If tank is metal, list age: _Is age confirmed by certificate of Compliance(yes or no): (attach_a copy of certificate) Dimensions: 4' WIDE X 10' LONG X 4' DEEP I Sludge depth: 4" a t Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: NO NE Distance from top of scum to top of outlet tee or baffle: N/A (LIQUID LEVEL IS 32") Distance from bottom of scum to bottom of outlet.tee or baffle: N/A How dimensions were determined: TAPE MEASURE Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): THE LIQUID LEVEL IS 32" AND SANITARY TEES ARE PRESENT AND IN SATISFACTORY CONDITION THERE APPEARS TO HAVE BEEN SOME EXFILTRATION AND EVAPORATION DUE TO THE EXTENDED PERIOD OF NON USE THERE ARE NO ADVERSE INDICATORS GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete_meta_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-integrit}; hqu�d levels as related to outlet invert, evidence of leakage, etc ) 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KE TI Date of Inspection: DECEMBER 12,2001 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 I UTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet-invert:,2'-BELOW'INLET INVERT Comments(note if box is level and distribution to outlets equal, any`evidence of solids carryover, any evidence of leakage into or out of box, etc.): THE BOX IS LEVEL AND THER ARE NO ADVERSE INDICATORS LOW LIQUID LEVEL APPEARS TO BE FROM EVAPORATION 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.): 8 Page 9ofIl OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `SYSTEM INFORMATION (continued) Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type X leaching pits, number: ONE 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-): THE COVER IS AT 10" AND THE PIT IS 6' DIAM'X 6' DEEP'(EFFECTIVE) THE'PIT WAS DRY AT" THE TIME OF THE INSPECTION THE BOTTOM OF THE PIT IS 10' BELOW GRADE. THERE IS AN OLD KITCHEN SINK IN THE BAS'k NT'A�D THE-DRAIN TERMINATES IN THE GROU16 I ' RECOMMEND REMOVAL'AND INSTALLATION'OF A"SINKWITH A DRAIN PUMP CONNECTED TO THE SANITARY.SYSTEM. ' 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.) 9 Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continu.ed) Property Address: 2_SOUTH PRECINCT ROAD Owner: STANLEY KECTI Date of Inspection: DECEMBER 12,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of sewage disposal system including ties to a t least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. locate where public water supply enters the building. REAR BSMT SINK WATER'LINE 29.8' 30.4' 32. 33.5' 40.0' 52.5' 56.51 5 NOT TO SCALE 10 Permit Number: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Z S'ov7 K l7ju:GiJ " iI�a�'- C C%�'lY� Lot No. Owner: Address: Contractor: Address:. ' Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................:................. Date I L Q on h/day/year STEP 2 Using Water-Level.Range Zone and Index Well Map locate site and determine: OAPPropriate index well.................................................... 7i3 OB Water-level range zone ..................................................... D STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... �� 0! �`'� .Y= 1 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ............................................ 7 STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) jfrom measured depth to water levelat site (STEP 1) ............................................................................................................. ��.3 1 Figure 13.--Reproducible computation form. 15 Page 11 of l 1 ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 SOUTH PRECINCT ROAD Owner: STANLEY KECTIC Date of Inspection: DECEMBER 12,2001 SITE EXAM Slope LEVEL WITH>19.8' DROP TO MAPLE SWAMP AT REAR. Surface water NONE OBSERVED Check cellar NO SUMP OBSERVED Shallow wells NONE OBSERVED Estimated depth to ground water >12_3 feet Please indicate(check)all methods used to determine the high groundwater elevation: X Obtained from system design plans on record- If checked, date of design plan reviewed: 10/12/77 X 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) X Accessed USGS database-explain. CAPE COD COMMISSION MW'S You must describe how you established the high groundwater elevation: A HAND LEVEL SURVEY DETERMINED THAT THE,DRY RED MAPLE WETLAND AT THE REAR OF THE PROPERTY IS 19 8' LOWER IN ELEVATION THAN THE LOCUS OF THE SAS, ASSUMING THIS IS DEPTH TO GROUNDWATER AND USING FRIMPTER METHOD THE ESTIMATED DEPTH TO HIGH WATER IS 12.3'. THE DESIGN PLAN FOR PERMIT#78-7 SHOWS A TEST PIT ON 10/12/77 WITH NO WATER AT 12.3' I1 L 0 C A glo9FK) SEWAGE RIPIT NO. e VILLAGE IN.STA LLER'S NAME & ADDRESS 0 1..• k - BUILDER OR OWNER ' 1. �c�RQnRTtt ] DATE PERMIT. ISSUED - 07�S DAT E COMPLIANCE ISSUED E ' T 00, i �. No.- .....:._.... Fps. . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................ ...E}�?�~.---....OF..... `...... ��:.....-............. ....._.................................. AvOtration for UhipmFai Works Tnnitrurtinn Vamit Application is hereby made for a Permit to Construct P<'or Repair ( ) an Individual Sewage Disposal System at ..................LEC7._*---I--- ---- ........P.................... Loc on-Address or Lot No. 11 •'• Owner _ A�ress - -a -- - -- -- -- - ---•-•------- ...... ` S!•—xJC1' '+•'Lc'T Installer Address Type of Building Size Lot.abr. ......Sq. feet Dwelling—No. of Bedrooms________________,___.____..._.__._______Expansion Attic ( ) Garbage Grinder (tJ per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ' ) Q' Other fixtures ------------------------------- ----•--•-----•------•--------•--• ------------ ............................................................. W Design Flow....................' ................gallons per person per day. Total daily flow................ .............gallons. WSeptic Tank—Liquid capacitAC?. ,_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width......0.............. Total Length.._.......T-.__._. Total leaching area....................sq. ft. Seepage Pit No.......I.............Diameter..: : __.&. Depth below inlet....� ... Total leaching area..P�/__,.Aj..sq. ft. Z Other Distribution box ( ) Dosin&Jaank ( ) r Percolation Test Results Performed by.... a-_ .............. Date........ Test Pit No. 1_ �_.�..._.minutes per inch Depth of Test Pita_:e'` Depth to ground water--_.A,t' A-__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ��JJ O Description of Soil------ ......�- ••9------- �.... 1 j 1�.•Jt' ]zzfi �``��b .��� d13� x W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------•---...--------------------------------------------------------....----------------------•------------------------•-----------------• ............................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n ' su y the and of heal. Signed.--- -• = -------- -•....... ..':..At .�- A Application Approved B . , 1 � '� &"rT`� 61P• ` Date PP PP Y _1 ..O.1r' �t � 7........................... ( =- ......-�.. Date Application Disapproved for the following reasons-----------------------------•------•---•-----•-•-----•------------------••-•-----------•-----------------------•- ------------------•----------•-----•----......_.......-------------------•....----------••-------•------..._.._.._...----•--•-------•-------------------•-•-----•---------- ............................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F H Tf-1 ........ .. ... -.......OF. ,.._.....------•--...--•----•-•------ _ for j3hipos al Worlks Ton,strurtion ramit Application is hereby made for a Permit to Construct P<or Repair ( ) an Individual Sewage Disposal System at Loc on-Address or Lot No . .. --- r . .. ... Owner ess W ... Installer Address} Q Type of Building �+�, Size Lot��_ _.._..Sq. feet. Dwelling- o N . of Bedrooms.................! ......................Expansion Attic ( ) Garbage Grinder C�/r pa, Other—TypeA of Building ............................ No. of persons............................ Showers ( j — Cafeteria ( ) A4 Other fi es _. W Design Flow................ -__ __gallons per person per day. Total daily flow_______ .............gallons. WSeptic Tank—Liquid capacitA .gallons Length...... ............. Width________________ Diameter .____ Depth................ x Disposal Trench No ............ Width_-. a.............. Total Length_.____.__ Total leaching area _;_ _... sq. ft. Seepage Pit No___._. ._. Diameter �'4_ Depth below inlet.... Total leaching area_� sq. ft. z Other Distribution box ( ) DosinLi�nk � _ .•. _ •_ _Percolation Test Results�w.� Performed by. �c, •_• _ ............... Date........ a Test Pit No. 1.1.:V.____minutes per inch. Depth. of.Test Pit.... Depth to ground water___ ( Test Pit No. 2................minutes per inch Depth of Test-Pit_______..._________. Depth to ground water........................ x --- ......................�r� , Description of Soil------ °'� :--------I" ► ••-•- �1 •. 7....... e!) W ----•--•---•----------•--- •------------ -••-•-------------••••••-•-••._....-•••--•-•-••----•-•-------,----:_-:__..---•----••-----••••-•-•••-•-•_...•••-•••••-••••-•-•••-.._.._•......_.....----_.... UNature of Repairs or Alterations—Answer when applicable.­-.,--._________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary Code-..-The unde signed further agrees not to place the system in operation until a Certificate of Compliance has be; suYdy the and of heal h. Sig 1� - ---I.....&..... Date Application Approved By - �- +fir -) ate / Application Disapproved for the following reasons:.....:.........•-__.Il..�___________________-__•________________-____________-- ___-___---_-.. --•-----•------------------------•-------•-------------------------•-----------................................................--•••••-••••----••••••-•-•••••-•••••••-••---•-------••••-••••--•-......_ Date PermitNo......................................................... 1+sued_........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH OF.......... ... . ..............._.............................. (Intifirati of autpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (, ,�or Repaired ( ) by . •-------------------------------------------------••••-•--•••----••--- = Instal has been installed in accordance with the provisions of TITEE• 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit'No...-*`...Z_______________________ dated----1.._-�-_-Z_:7..................... THE ISSUANCE OF THIS-.CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE,THAT THE SYSTEM MILL FUN TION .SATISFACTORY. DATE.. .:.:.: - Inspector.:. !! lY THE COMMONWEALTH OF MASSACHUSETTS BOARD OF" HEA T ........ _ .. ..........OF..-...-•y ,�� �� ".......................... No.......... FEE..... 3 �." 13isposaal 1vorkg %,1. 0 11trndilan Wrmit Permission is hereby granted- .......................... ......••.......... ............................................. to Constrio or Repair ( ) aA Individual Sewa 7DI Ipo al Sy _. at No._ Street as shown on the application for Disposal Works Construction Perr No___ ______________ _ Dated_.__ /. _. _ ..___•-...._. f ................................ oat of Health DATE................... _ ?EI. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS' - No TIC 7--o4lV/C _. : _.. _ lIG '� _ E x � T /O Jyvw!$••.�ElC A. COMEM5 �_ .t Y M1 ., �•4 PVC �/R.�.' - �.... < � � fi _CONCRL'T.�' JE.4Yy C.A STl�"P�N. G I/ER S`h�.�L L BE U. E.D � e -. 1 - - - — - 2 pia: • A o: _. .- _ C LEAN SANG G of d✓ C - - UQU/O LEVEL -_ =• - � _ - .,. f d 4'"CAS� - - >. �ar�rr•' 2+LAYE_ - .11: /RON P/PE /®f5 ID" o a c " OF ` ..b MIN.P?GN CPA4. - T, o e 7i7iYE PAR mot- S,CP7'/C T.gNK o/s WASHED ,S ; - n e • "EFFECBox T/VE i =. _ _ o °- ! • ® DLsPTf/ ° ° e ° e �jo __ WASN.ED STONE 1p ,, ; - ' " e v4 e • • • o o • • 1 • p ot�p PRECAST SEEPAGE o" o v 1 • '• a • • 1 1 ' a v P/T OR EQU/ei - - � - /NXERT AT BU/LD/NG o clip �T -. 6 tT O/AM. - .� 4NZET .SEEPT/e_' TAf/VK -"O/,6S f T• ,0_ FT. 9/.4M. ; C(SEZ 70UW"7JONl) `- DU �Z-T SEPT/C TANK 9g,3 'FT_ -VIVLEr-Pj57 Z011T/ON BOX 981 --7 . ' - `GRpuNO x�TER TA,'8LE - - .SECT/O/V O F - OtlT�tTDe STR/B1lF'iOIV BOX rl /NL'ETSEEP.�IGE' O/T `/7,5 FT .S�'�(/AIP E 015,4705A 4 .Se.57 E_&A! j -r,4;Jta1_.w-r/®w DeES Y ,A 3 FT. h A/ CR/TER/A - 10/MEN3/0A/ 13 _. 6 FT. t NUM®ER OF®E®ROOMs 3 D%MEN:i/ON G ' GAR®AGED/SPOSAL (/iylT SDI L_ .LOG - .. . TOTAL EST//MATED FLOW G.4L./Di1Y . SOIL TEST;�4s/ So/L T.FSTc�2 TE.�T - NUMBER a4gr 55fi!'P46Z P/TS_ _. . E[�Y, I o d•D ELEY, .DA)TE OF SOI; TEST ;" w�� /�-7 _ S/DB 4EACI4/NG-PgR P/7• 8 .Sq FT. 07..-IVI RESUA rS P1/1TjAl/&S5EO BY. •P A31--N S';I<I 41 ®OTTOM LEr�CN/NG PE1i P/T l 54. FT PERCOLAT/ON le.4TE#/ J 1'?//VaJtNGH- ` y TOTAL LEACHI, IV& AREA Z 6 SQ. 'FT. FFNCOL A77aN RATE fk2 /tESERVEd.FACillNoSAREA` z��`�'$!,� FT �� Scl3s t- V0!FIt% MA r IL O re // . t.. t _ Sf �d = '�! 'A9A/ v BT.• ,' 9s5Pfi%: ip �. ZI Lv �• .gip ;Y.4 Sp A�/'f" !12 S t r 71 Jrl y> S,i,uS �.•.�y ti � . •�v.•A N.�. x,rtt? � ,•,.. 1- a' � �Y t -,. ` �! cry ttnw� t a. ^1 i t ,1 t.;� 7 t 4, • 'y,_ ..p f y ; # "MNI Yiy, ot� t ! C T2, '. t rAi,' /� `f' r i E• ' Y rk } � ,err, t'���.,.(/• / ° .^'�l�';r I W tt 4 C/ / ", / 3 , Y d t.,., {t'�(. r 6 w ' t{h 4: MY' r.r, a' ;-••t�i ';7 a i-' r -i '�f tf ,.! 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(p d p f,. s� S,Tt-, 1 r .. � ,nr e 1 , ;r`• x y', X'i`I+�, �{ �i�yy }1Ms +, •R, #Y#�y hv�.l w �I' (. � � Z{�`�j R{)p�tY) ,� '^ ,L�.,� 9r'i �.. ° ` } yt '• It � ±.! °I /rt .t�. i a<4-'; a� x F`pgv �,�vl� r `;� t�.r, c (d !'•r , I_ t , �'1 r, E•$ '4 ��' t N,:e �t � 't'F tid..� "1° ✓ �a ' J", t rL I 5,• 34, �''.. ° J r" ';,; 52.. ft py•�!f 'trJ�t .d Y' r r !4�d,_ `it i±2%F 4.1� 7 k. m�y 37 � yl,.' t ,.. r.• a s... 4r /., � �i kf�y 'i �7 tnx rt+ t I.bDC'i yA'L. � dE• t. I Y Ji ti v, ;,; b� *" .v f�# v1. °rA/K r, ..iyarnt 'h r � �q7Y�yt+�•p.a'r v 1' Icy' dI ocii1J 72,�J• �u } - i ' d .iM ��; 4��,+� r xn;. j // It s m�' ty �Y � ,#N pcAii.` ,. ..! r sue{ ., 1 ` t d t .� �rI#.`fj ', >I� '..?•� ,�i a,{ ii i.' I ,i: if '1 'h 7Y ty I�' w's ��t i i i �e. 3 r 'v a: s I • n 11 I t ., � p,::ih,y�t�^v, t, na ZH OF, r , tt v r ;li r�, M1 t s ° t ih dj !, I o �cr S # . Ey i1, `., r •'t IP t��4 ilt yw •:I Vs eA y, I tlry I. 41 t y ..u . R,� ,yn 'vrp i:. rbM1k� r, # k f + O ROSE'71 tC 7 s WI rWt �qu: I i , ° !�A :'•P I e.. t1 , ., r k� t t a aY•V 'x t .A + ! 9 1 y r r A 1 °; " i .y: t 'gUNIKI tr � o NM 22162.1� a . L e _ n- S'i�.t� !x v}. f t#9 ' yt ,t Y'{ n�t£r'{ a 1 ' � �..� 3Y •*� s ss.'p NA�,"�N\ � , }�'. t,. I s 1 q., �+ 9 t k r f , ;} w CERTFFIED PLOT „�-A�' K s? NOi SPOT EL `�/ATION�,; 0 0 ' "1 ;�40NTOU R p sl t fi �t : -=---, i C�`!- ./,9 sa v7-,-1 19kc '/ Fil! b SPOT a ELEVAT Lu t�l �-�' <-- ' 'CONTOVR k` 0 —r- F _T�-/�'V14,1 I N r= BOvARD. , OF 'HEAi.TH Ff AS + x' t t u1 'i p� r ?,� 5° _.tti I�t t k r 1 ;ri' '• 4 ., // / • - +rYi ,.. ,� .� AGENT, „ar SCAL'Et., DATE :"'•/ 0� V77 Y ' t: CLIE4T4/ET%NO3 I "CERTIFY 4 THAT THE PRO0OSED g Is RE REGISTERED, JOB,..N0 77 .S. BUILDING , SHOWN `ON THIS PL AN rE N�QtA C VIL L . NO CONFORMS TO THE ZONING LAWS ' EER SURVEY R DR.BYt;, 0 r1 M. OF , BARNS BLE MASS. 41 (MAIN ST 712 MAIN ST. CH- By — µ4 SCS 'Y,XARMOYT.4, MASS. HYANNIS, 'MASS: - - SHEET_L OF bA E . <• REG. LAND SURVEYOR Jj (k *�E