HomeMy WebLinkAbout0047 TARAMAC ROAD - Health 47 Taramac Road
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is required for Centerville MA 02632 March 9, 2010
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. :y
Important:When filling out A. General Information T-ate
.. �
forms on the
computer,use
Inspector:
only the tab key 1. p
to move your Patrick M. O'Connell ° ' 1
cursor-do not Name of Inspector s
use the return
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508-428-1779 SI 12855
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate'and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
AA March 9, 2010
I pector's gn-a ure 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.
10-60 Emerson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
TOWN OF BA(RNSTABLE
Ln-ATION �'� 1��C�a�VI�C- �c-� Ste# 'r
VILLAGE&hZ 040 ASSESSOR'S MAP&PARCEL
IId �'S NAME&PHONE NO. ca�r►�(=®•�,e X�4,1) L L -! "►1�'
SEPTIC TANK CAPACITY 1000 SJ
LEACHING FACILITY:(type) (size) l000
NO.OF BEDROOMS
OWNER &KktScn n
PERMIT DATE: C ATE:'T,15J? tGj Ip
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
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f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is Centerville
required for MA 02632 March 9, 2010
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank is not in need of pumping at this time overflow leaching pit was empty at time of inspection
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 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
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is required for Centerville MA 02632 March 9, 2010
every page. Cityr'rown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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
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.
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is required for Centerville MA 02632 March 9, 2010
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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
El ® 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.
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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.
LIO-60erson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Cltyfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
10-60 Emerson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms 3 3
(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
p pump?
.� ❑ Yes ® No II
Last date of occupancy: Currently
Occupied.
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
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 a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 3"
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth: 01.
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 011
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Measured
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank had liquid only, no solids. Liquid level was found at bottom of outlet invert, tees were intact and
clear.
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene
El 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.):
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):
10-60 Emerson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet 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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G M 47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: Two pits in
series.
❑ 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.):
Overflow pit was found empty with a high stain line at 50% capacity.
10-60 Emerson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is
required for Centerville MA 02632 March 9, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Privy(locate on site plan):
Materials of construction: i
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
10-60 Emerson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Taramac Road _
Property Address
Dennis Emerson
Owner Owner's Name
information is Centerville MA 02632 March 9, 2010
required for —
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
Taramac Road
Watre
Service
24 2
3 34
28 5
t
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,..'� 47 Taramac Road
Property Address
Dennis Emerson
Owner Owner's Name
information is Centerville
required for MA 02632 March 9, 2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 20+
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:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el. 25 and topo map shows property at el 40
10-60 Emerson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
TOWN OF BAJRNSTABLE
LOCATION 1 AGA AL �C• SEWAGE #
V AtLAGE C.G/1 RnILI-LL ASSESSOR'S MAP & LOT��
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY (RA-)
LEACHING FACILITY: (type) c�-' ��� S (,X L (size) /0D D
NO.OF BEDROOMS
BUILDER OR OWNER �Ol)OVAn
PERMITDATE: 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) Net
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility,_ Feet
Furnished by ^SP-c(,l lb - -)
AU
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► �y a3
3 S 3$�
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TOWN OF ARNSTABLE
'] �
LOCATION l c,,^A&AC '` SEWAGE #
VILLAGE NI ��n ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. CG
SEPTIC TANK CAPACITY vt ntfce 0AL ,
LEACHING FACILITY: (type) (siz
NO. OF BEDROOMS
BUILDER OR OWNER oh& V�✓�
PER MITDATE: COMPLIANCE DATE: �C U
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 r. "
f 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) reet
Furnished by ^
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No. // Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ye
ZippYication for Oizpooat bpgtem Con!5truction Permit
Application for a Permit to Construct( . )Repair(A' Upgrade( )Abandon( ) El Complete System 2116div—idual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. Sa 8' yaZ D- 7 ySy
5r 7 7A�'.4 A c 2 _Di o�A V4.v �c&x,
Assessor's Map/Parcel 10
rif / 1, -7A R/gIn 4 c R� C [,1i7—
C£.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
C/ati� °
3 S° pyj�i.�- ss �•- Y��
Type of Building: �o u C
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) F '� C 4 .y £
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 issued by this Board of Heal
Signed �`" Date y
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �' Date Issued
-- --------------------------- — —————
r No.0400 , Fee
f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
s
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for-Mi5po$al *p$tem Cgttgtruction Permit
Application for a Permit to Construct( )Repair(A<Upgrade( )Abandon( ) O Complete:System 1 i"ndividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. So y o- 7 %3 y
y 7 ?A,P A M g C � 1 a YvA vl�1v
Assessor's Map/ParcelA c iP
Installer's Name,Address,and Tel.No. ;' Designer's Name,Address and Tel.No.
14) �
L ply
Type of Building: Pou 5 r
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) '��'� C r 4 'y
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 issued by this Board of Health. �•
Signed /, i _ �y I—� Date
Application Approved by Y Date
Application Disapproved for the following reasons /� f
r
/-t
Permit No. Date Issued
n e n THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE MASSACHUSETTS
Certificate of Compliance
THIS IS TO CURTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( )
Abandoned( '•)by A �e C 11 Al CO 35� 7-
at V 2 ?,�J s'r i1 Al/) c R F.41 1— has n constructed in accordance
with the provi ions of Title 5 and the for Disposal System Construction Permit No. -dated
Installer *r%n2&a 1esigtter r
The issuance of this permi shall not be construed as a guarantee that the system wil f unction designed r
Date 1 Inspector '! `� 11 n (��
U o -
__a _—
_
No._����(./ -----------------------'—Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migaaf *potem Con!5tructton Permit
Permission is hereby granted to Construct( )Repair( ')FUpgrade( )Abandon( )
f System located at `� 7 �� /Ril C IP C F:C-T
f
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5;0s/
following local provisions or special conditions.
AProvided:Constru f b co 'pleted within three years of the date of this pe `t. —
Date: / Approved p by.
PP
f
TOWN OF ARNSTABLE �
LOCATION / T//c4 ran✓t^A C /C SEWAGE # 1
VILLAGE Cg, N, °l�P ASSESSOR'S MAP & LOT 16 -06 3
INSTALLER'S NAME&PHONE NO. Cco
SEPTIC TANK CAPACITY Rf, n rp L oA k/
-LEACHING FACILITY: (type) ($tz
NO.OF BEDROOMS
BUILDER OR OWNER o n r, V-1
7—PERMIT DATE: �{ COMPLIANCE DATE: a2c U
Separation Distance Between the:
Maximum Adjusted Grou-ffdwter Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and.Leaching Facility
pp y g (If any wells exist
on site or within 200 feet of leaching facility) feet
ge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) eet
Furnished by
o
°
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 47 Taramac Road
Centerville, MA 02632 T
Owner's Name: Donna Donovan �y
Owner's Address: /
Date of Inspection: March 3. 2006
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
_ Osterville,MA 02655-0049
Telephone Number: (508)862-9400 3
CERTIFICATION STATEMENT I
:ram
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 perform"e`d'based off—my f-j
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 15340 of Title 5(310 CMR 15.000). The systems : n °
✓ Passes
Conditionally Passes •z
Needs Further Evaluation by the Local Approving Aut rity
Fa' s
Inspector's Signature: Date: March 8. 2006
The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of comple ' g 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.
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 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Taramac Road
Centerville, M.4
Owner: Donna Donavan
Date of Inspection: March 3. 2006
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:
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 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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Taramac Road
Centerville, MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006
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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART A
CERTIFICATION (continued)
Property Address: 47 Taramac Road
Centerville, MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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.
✓ 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 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. [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.]
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 System:
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"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 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 e
r
Page 5 of 11
e
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 47 Taramac Road
Centerville, MA
Owner: Donna Donavan
Date of Inspection: March 3, 2006
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 f o 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
P P P
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
✓ _ 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)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 47 Taramac Road
Centerville, AM
Owner: Donna Donavan
Date of Inspection: March 3. 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No.
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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:—Pumped in 2005 per owner
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 a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Y Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Taramac Road
Centerville,MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006'
BUILDING SEWER(locate on site plan)
Depth below grade:
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 on site plan)
Depth below grade: 3"
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: 1000 zal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
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.):
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Taramac Road
Centerville, AM
Owner: Donna Donavan
Date of Inspection: March 3, 2006
TIGHT or HOLDING TANK: None(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: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet 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.):
PUMP CHAMBER: None (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 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Taramac Road
Centerville, MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'0000 gal.)
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 original leach pit#3 was full up to the outlet pipe. The newer pit#4 had 3'of water on the bottom There did not appear
to be any signs offailure. The bottom to grade was approximately 9.5'.
CESSPOOLS: None (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: None (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(continued)
Property Address: 47 Taramac Road
Centerville.MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties tout least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A 8
QAt
4 �
y
3 S 3 y�
y 8 sy
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Taramac Road
Centerville, MA
Owner: Donna Donavan
Date of Inspection: March 3. 2006 _
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to.ground water 20+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of'design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the nt Ps were showing garoximately 20'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees,either expressed, written or implied,relating to the system, the inspection and/or this report.
11
IE
.� TOWN OF BARNSTABLE
I.
:-ATION �� ` Y�1 d4 G� SEWAGE #
AGE ���-e�- ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
^SEPTIC TANK CAPACITY 1� S• 1
LEACHIIJG FACILITY: (type) _ I t�ec,e (size)
NO. OF BEDROOMS
BUILDER OR OWNER SOS
—PEMMATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �S' 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 N Feet
within 300 feet of leaching facility)
Furnished byC��-�
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CO` NIONWEALTH OF N kSS?.CHL'SETTS
EXECUTIVE OFFICE OF ENNIRONMENTAL AFFAIRS
_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
�' O\'E WINTER STREET. BOSTON. MA O:IOS 61 i-:S:•�:QG , 1
ao : nn 2
U-11-L1A-1 F.WELD �.,.. . _ "'" �, C_0?-
0,,RGS
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A0 FA'UL CELLL'CCI = "R+ ��ly 91s ll' B SKi�t
Lt.GaVC771017' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , Fo�gB� Co irr_.
PART A • . - ' • =:-��• }
CERTIFICATION _ .
to
Property Addres,; `K. Address of Owner. LM s k A VV,r,
(If diiierent)'
Date of Inspection: ��4 9� U(�� _
Name of Inspector. - I d=C�ca
1 am a DEP ap roved system inspector pursuant to Section 13.340 of Title 5 C310 CMR 15.000)
Company Name:�/ .7 vr•��'e E,l A-r-r'^r. wt P M !..
Mailing Address: 2 Q /;Q�c !C_37?'U h'"Ke o H PT C7 2L,4-q ,
Telephone Number: rSC2t72 L.4p__ L,c
CERTIFICATION STATEME\T
I cenif that I have pe,sonally inspeced the sewage d!spcsal systern at this address and that the information reoerted be-oN is true. accurate
and comole!e a5 of the time of inspec:.a-. The inspecton %as pe-iarmer base: on my training and experience in the prcper iunaicn. anc
maintenance of on-s-te sewage disposa� systerns. The syimm:
Passe:
_ Concit-onaiN Passe:
♦eect Furthe- Evaluat, R Ev the Local Approving Autnarim
Inspector's Signature. 4Date: 4
T,ie Svs:en- InsreGr sha" subma a copv of this inspeC,on repay, to the Ap;,rcving Authority• within thin^ (30, days ei ccrnplesing this
inspection. It the system is a shared system o- ha. a ces,gn flov,• of 10.000 g--c or greater, the imec cr and the sys:e•n ewner sha!l submit
the re:o- is the a--vccriate revoral afiice of the De;a-rnent of Envircnmenta' Froteczicn. The er,g-na! should be sent tc the system a ne-
and copies :-n: to the buVer, ii applicable. and the apvcving authorit\
INSPECTION SUMMARY: Check A, B, C, or D
:zy
PASSES:
ave net fcund any information which indicates that the systern violates any of the failure criteria as definedin 310 C.MR 15.30.3 failure citeria not evaluated are indicate-- below.
COMMENTS:
31 SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pus- seclion need to be replaced or repaired. The system, ucc
completion of the replacernent or repair, as approved by the Boatel of Health, will pass.
Indicate yes. no, or not determined (Y. N, or NDi. Describe basis of determination in all instances. If 'not determined', explain why not.
The septic tank is metal• unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (anachedi indicating that the tank was installed within twenty (201 years prior to the date of the inspection: c
the septic tank, v.-hether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, ae tan:
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic cnk
as approved by the Board of Health,
r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION (continued)
Property Addtos: .
Owner:
Date of Inspection:
ej SYSTE&A CONDITIONALLY PASSES tcontinu,!�d
_ Senate backup or breakout or high static water level observed in the distribution ox is due to broken ' obstructed
pipe:sl or due to a broken. settled or uneven distribution box. The system will ass inspection 9(with approval of the
Board of Healthi. Describe observations:
broken pipe(s) are replaced
obstruction is removed :.
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to bra n or obstructed pipetsl.:The system will pass
insoection if tw•ith approval of the Board of Health):
_ broken p►petsi are reatace:
obstruction. is removed
C] FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which n-auire furthe• evaluation by the Board of alth in order to determine if the s}•stern is fairing to prate--. the
public health, s:ieti• and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH OETER,MIN THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE E'�VIRONMENT:
Ce_scool or privti is within 50 fee: of a surface wa n
Cesspoo! a. pri%� fee: a:is within 50 fe Oi a border' g egetated wetland or a salt anrsh.
Zl SYSTE.� WILL FAIL UNLE55 THE BOARD OF HEALTH N0 PUBLIC WATER SUPPLIER, IF APPROPRIATE: DETERMINES THAT
THE SYSTEM IS FUNCTIOti1tiG.IN A MA.NNER THAT P OTECTS THE PUBLIC HE-kLTH AND SAF Mi AND THE
ENVIRONMENT:
_ The mtern has a septic tank and'sail abso tion system (SAS, and the S1L is within 100 fe-e: to a surface water supply at
tributary to a surface water supo)y.
_ The system has a septic tame and soil a' crpticn system and the SAS is within a Zone I of a public water sup::iv we!1.
_ The syste-n has a septic tans: and soil sorption system and the SAS is within So fe•_t of a private water supply well.
_ The system has a septic tank and spill absorption systern and the SAS is less char. 100 fey: but Sd fe-_i or more from a
uniess a
private water supply well, e!I water analysis for coliform baceria and volatile organic compounds indicates th
the we!I is free- from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to c
less than 5 ppm. Method user t determine distance (approximation not valid).
3) _ OTHER
(rev-.Sod 04:27/77) Page 2 of 10
r
� d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert% Address:
Owner: �n
Date of Ihspection:
L
FLOW CONDITIONS
RESIDENTIAL:
Design floN . - 9 p.d.,Ibedroom for S.A,S
Number of becrooms 1!>
Number o' current residents-AD-1
Garbage g•. der (yes or nor
Laundry co.—ected to system (yes or no!
Seasonal use Ives or no%h.,>
Water meter readings, if available (last two :2 year usage tgpdi. N
Sump Pump Ives or not
Lai: da:e o'occupancy 1\3
COMMERC;kUINDLISTRIAL:
Type of establrshmen:
Design fiw% ea!ronsioa\
Grease trap present ryes or no_
Indus:na! \Taste holding Tani; presen: Eves or no
'�on-sanita'\ waste drscnargec to the 7rtre 3 sys:ern ivec or no
\\ater meter readings if a•arlabie
Las:Pave o: o c..;,z.,c%
OTHER: .:De:crrbe
Last cate of occuc;a-rc.
GENERAL INFORMATION
PUMPING RECO S and source of rniormatron
'' T_4 S j►'j r-' 2( t w%—k
System pum a as par, of tnspec:ron. Ices or no.
If yes, volume pumped eallons
Reason for pumping
TYF SYSTEM
Septic tan -sort absorption system
Srng:e cesspool
CTvertlow cesspool
Prn) -
Shared system (yes or no) (if yes, attach previous inspection records, if any) _ _.—
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _- � `��} Z_ _ Ar" x N ,'%Jr.
Sewage odors detected' when arriving at the site. tves or no)
(re,iaad 04/25/91) Page 5 of 10
S126SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Property Address-
Owner: (1-U)f1i
Date of Impection:
BUILDING SEWER: T7
(Locate on site plan)
Depth below grade.
Material of construction. . cast iron _40 PVC _other (explain'
Distance from private water supply well or suction It
Diameter
Comments: (condition of)oints, venting, evidence of leakage. etc.)
SEPTIC TAhK:_Ims,
(locate on site pla.
Depth belo\& grade
material of construaio ,tconcre:e _me;a _Ftoe•g:a55 _Polyethylene _othertexplam
li tank is me;a:. Ifs: age _l1; age coniirmeC o\ Ce^.nca:e o; Compitance _,'OesNo
Dimenstor! 1QCY)nA-
Sludge depth ;i w
Dtsiance from top o: siucee to boron o' ou:;e-. tee o• ba':e �
Scum thickness N
Distance from top o. scum to top o` outle: tee or ba a —a— ►�
Distance from bonorn o' scurn to bo-o-: o; outlet tee c• bah.e 1 _.
hov+• dimensions \ere determined
Comments
trecommendation for pumping. Condit on inlet -no o-jtlet te=5 or baffles. depth of Itqu;d level to reiatton t ou let inve structural
int rtty, e.idence of le �aee, etc ) t �Q 1 ''
t bib. t.
GREASE TRAP:,
(locate on site plan:
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 bonom of scum to bottom of outlet tee or baffie:
Date of last pumping: - --
Comments:
trecommendahon for pumping, condition of h,let and outlet tees or baffles. depth of liquid level in relation-to outlet-invert;structural ---- ---- -
integrity, evidence of leakage, etc.;
(r-,*,a d 04/25:97) __ Paco 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PARTS
CHECKLIST
PropertYAddress. 1 �i'�r}1nnR ►�
Owner: I h.;v^pL.y- tJ
Date of Inspection: '111 c
Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following:
es No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least 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 pan of this inspection
As built plans have been oorained and evamined. Note if they are not available with N,A.
_ The iac!lin or d.+eliing "as inspected for signs of sewage back-up.
k _ Tne system does not recei+e non-sanitary or industrial waste flow.
*� The site .+as inspected for signs of breakout.
_ All s.sterr. components. eacludine the Soil Aosorption System, have been located on the site. r
The sept.c tank rnanhoies "ere uncovered. opened. and the interior of the septic tank was inspected for condition of
bafiies or tees. matena'. o-construction• dimensions. deptn 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
'`x-► The iac,l t\ o\+ne ano occupants. ti cliheren: trom owneri were provided with mi,ormauon on the prope, maintenance of
Sub-Suriace Disposal Svsterr..
Existing iniormation. Ea Plan at B O H.
x _ Decerm,ned in the field tr an,, of the failure criteria related to Part C is at issue. approximation of distance is
unaccmabie 113.302,31:blt
(r.v1..d 04/:5/5'1 P.q. 4 of 10 '
SUBSURFACE SEWAGE DISPOSAL SISTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properh Address:
Owner: .-
Date of Inspection:
L7j SYSTEM FAILS:
You must indicate either "Yes" or -No' a$ to each of the follvwing
I have determined that the system violates one or more of the following failure truer a5 defined in 310 CMR 13.303 Tne oasis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overl ded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or su ace waters due to an overloaded or clogged SAS or
cesspool.
Stoat !ieuid level in the distrib,,tron boi. above outlet invert du to an overloaded or clogged 51,5 or cesspoo;
Lieuid cepth in cesspool is less than 6" below invert or avail ble vole ne is less than 1/2 day flev.
Reeu'red pumping more than 4 times in the last year NO due to clogged or ebstructea pipe 5 .
'�umoer o' times pumped _
Any portion o:the So!l Adsorption System, cesspool o pnv)- is below the high groundwate• eievatio-
Am por:on o"a cesspool or privy is wahir. 100 fee of a surface water supply or tnbuta,% to a surface Ovate, supplN
An) por,ion of a ce'_sc)oo' or pri%)- is wrthir a Zo e I of a public well.
An% pc^jo-. e:a cesspool o• priv is within 5 feet of a private water supply we!!
Any por ..or. o:a cesspool or privy is less th 100 feet but greater than 50 iee: from a private water supply well with no
accezable Ovate, qualm anal.5i5 h the w• I has been analyzed to be acceptable. anach copy of well water analysis for
cohiorm bacteria volatile organic compo ds, ammonia nitrogen and nitrate nitrogen.
E] URGE SYSTEM FAILS:
lou must indicate ei:he• "Yes- or "No" as to each of th following.
The ioliow:ng criteria aop;. to !urge systems addition to the criteria above:
The system serve5 a faciljn with a design f ow of 10,000 gpd or greater (Large System; and the s\•stem is a significant threat to
public health and saien and the environ ent because one or more of the following conditions exist.
Yes No
the system is within 400 f t of a surface drinking water supply
the system is within 200 eet of a tributary to a surface drinking water supply
the system is located i a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply ell) :::.:..:: _•.. .: : ..:_:. ..: ..
The owner or operator of any such sys em 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 (or_furthe.r.iniormanon. ---
(rava ud 04/25/97) Page 3 of 10
SUBSURFACE 5EWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
�f�/ SYSTEM INFORMATION (continued)
Property Addr-ss:7 l T-�� ,
Owner. Tvmf sR�.Jt
Date of Inspectto//n:g��(��r
SOIL ABSORPTION SYSTEM (SAS): S
(locate on site.plan, if possible. excaT ion not required. but may be approximated by non-intrusive methods;
If not determined to be present, explain.
Type
leaching pits. number. C�
leaching chambers, number:_
leaching galleries, number.
leaching trenche<-. number,length:
leaching fields. numbe,, ci,mensioni
overflow cesspool, numbe-
Alternative system
name of Tecnnotogy
Comments
to to conduio of so i. s+grs of hydr uGc failure, ev ' of ondmg. n��uo f v tation, etc.t
431—
CESSPOOLS:
(locate on site plar.
Numbe, and co^ijg:;-a:-o-
Depth-top of liquid to inlet in.er,
Depth of solids lave,'
Depth of scum layer
Dimensions of cesspool
materials of constructtor
Indication of groundwate-
inflow• tcesspool must De pumper as par, of inspection
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 pcndmg, condition of vegetation, etc.).
tr.�:..e o.:zsis'> Page 8 or 10 .
susSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.m
PART C
SYSTEM INFORMATION (continued)
Propert,6 Address:
ON ner:
Date of Inspection:
TIGHT OR HOLDING TANK: lank must be pumped prior to, or at time, of inspectroni
(locate on site plan,
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions.
Capaciry gallons
Deng-: iloA galiors-da.
Alarm level A:arm in %%orking orde• _ Yes. _ No
Date of previous pump,ng
Comments
(condition of inlet tee. condition o• a!a•m, and floc: switches. etc.t
DISTRIBUTION BOX:_
(locate on site p a-
Dea:�i o' licuid te%e: aeo�e outie: in.e'-
Comments
(note c le e! and dIs:ribut-or is eeua• ev,dence of soles carr ove , e��dence of leakage into or out of boa, e!c.t
PUMP CHAMBER:
(locate on site plan_
Pumps in working order: (Yes or No,
Alarms in workjng order (Yes or No
Comments:
(note condition of pump chamber, condition /umpsppurtenances, etc.)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert. Address-
Owner.�tm
Date of Inspecuun:
i
Depth to Groundwater��S Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation o-' Site (Abutting property. observation hole. basement sump etc.)
Determine it iron local conditions
Cnec. %%,tn local E..ard o• -iea-t:-
Chec, F:%1:, &'acs
Cnecl, retorts
Cnec� local e.ca.xo•s ins:alle•s
3, use _5__ Da z
,.
Descnbe o,,- •o cs ec.. �o_ esac;-s,-ec ine 6—!:c C.ro-in cwa:e• Elevation (Must be co-•�ie!ec
S Nowdq
D.q. 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM
PART C
SYSTEM INFORMATION (continued;
PropertN Address:
Owner.1T10
Date of Impecti n:y)4 J� C
SKETCH OF SEWAGE DISPOSAL SYSTE..M.
include ties to at least two permanent reierences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house!
A ,
o �
V^
ell
(r.v�ea'_ c.•:s/s-1 Page 9 of 10 .
-l0 C A T 10N S E W A G E PERMIT NO.
IV 2
VILLAGE
I N S T A LLER'S NAME i ADDRESS
® U I L D E R R Owti
ATE PERMIT ISSUED
DATE COMPLIANCE ISSUED S/` 3
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36'4'
4
18' " T 1'- 9'4'
MdI Frt Bed
Lt Frt Bed,. m
{
UvIna Room
dfj
7
2 10'
to
m' closet f1)
14'10" 2
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j
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da,ecz rz1
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2,4 3' —2,4'
_ doset4(� NI Claeet3 t�
1 N ,
- DIne/Kltshen �
2,8
1_2'8'' in
is u
It 0.eer Bed
m
Vl �11
ITT 8'6"
f`
Main Level
EMERSON_D_REC,ON
3/19/2009 Page: 2
- 36'3d. .
19'3'
16' '
—11 Two
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A's
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urn„e.m�c I IC ul
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6'27_
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4.
28'
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m
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4
Basement
EMERSON_D_RECON
�l r7 7A ►"-i,444C. C'•��,��2v/L-Le 3/19/2009 Page: 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.......4Y......Tam) 'j
Installer Address
Z Other Distribution box ( ) Dosing tank ( )
U Nature of Repairs or Alterations—Answer when applicable-------)7j- a - 1. .0
----'—'-------------'---' '—'--'----
Agreeoeot:
The undersigned agrees to install theuforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I Ti!Z- 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 boy?theboa�d of health.
Signed..../. . . ... ... ..........
I Date
Date
Application Disapprovedfort6xfo8ozwingrxusonx:.------...--_--_---_--------_—.------------------'----
---------------------'''---`-----'---`-----`----------------------`-------'--''--''---'---`----
-..
| Permit No
| ..... Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
No.-V....�17_ Fimic..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............j ......I.....................OF................................I.-,....Z I/
..............................................
Appliratiou for Dispotial Works Tomutrurtiou ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
..................... ......4..................................
................................. .......;�----------------------------------------
Location-Address or E;.Ko
............................................2...................................
................... ..................................................................................................
Owner Address
Installer Addres s
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
A4Other fixtures .......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .............*...... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
Test Pit No. I................minutesperinch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix ----------------------- -------------------- ------------------*-----------------------"----------------- -----------------------"........
0 Description of Soil........................................................................................................................................................................
W
........................................................................................................................................................................................................
U
W
----------------------------------------------- ........................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable......................... .....11 - .1
...............................................................
............................................................................................................................. ........................... ..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT iZ 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..............11 / / I /////-,'/, /�,"e,� /
........................................v.......................... ................................
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:...............................................................................................................
........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............J.'.........I...............OF................... ............... .
f ........ "*'*"*...*......*..................
01rdifiratr of Toutpfiattrr
THIS IS TO CERTIFY,'That the Individual Sewage Disposal System constructed or'Repaired
bJ . 1 e - _/ I .
y--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
I Installer
at....... / I. - , .1 . I ....7--------
----------------------------------"......*------------------------------------------------------------------------------------------------------*---------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated---- ...........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WI�LFUNCTION SATISFACTORY.
DATE...... ........................................................ Inspector.. .......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ......................�OF................................................./
...................................
No......................... Disposal Workii TDonstrudion "pamit FEE.........................
Permission is hereby granted...................................... ..........
------------------------------------------- ......... ......
to Construct or Repair ( J-an Individual Sewage Disposal System
atNo..........L..................f�................ .................................
Str eet
as shown on the application for Disposal Works Construction Permit No.. .............
...........................................
.......................................... ........71..................................................
Boar of Health
DATE.......................................... ......................................
FORM"'1255 HOBBS & WARREN. INC., PUBLISHERS