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HomeMy WebLinkAbout0050 THISTLE DRIVE - Health 50 Thistle Drive = `i Centerville A= 171. -065 clll J,�a�► ° llll UPC 12534 No.2 HASTINGS, MN 1 i I Commonwealth of Massachusetts Title 5 official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 50 Thistle Dr (System 1 of 2 Front System) M Property Address Rose-Marie Cai se Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 ' page. City/Town State Zip Code Date of Inspection r-► 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. A. General Information S1 954 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 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 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furthe al tion by the Local Approving Authority 4-2-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °r 50 Thistle Dr (System 1 of 2 Front System) Property Address ' Rose-Marie Caisse Owner Owner's Name information is ` Centerville MA 02632 4-2-16 required for every: page. i City/Town State Zip Code Date of Inspection B. Certification (cont.) i 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined, please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts M W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. , B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °p 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool f o waters Discharge or ponding o effluent to the surface of the ground r surface w e ❑ ® 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 1 than /z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ANK Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s a'y 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if he following have been done. You must indicate "yes" or"no" as to each of the following: C t g av y g Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, ,M s 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 4-2016 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner--pumped within last 2yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ OverFlow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysb9m•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2008 new leach field Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24° 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.): Good condition. Septic Tank (locate on site plan): Depth below grade: 18"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: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 um in : p p g Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 �yY 50 Thistle Or (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Flame information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: I ❑ 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.): Leach chambers in good condition and empty at inspection with stain line at 6"off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids ,Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every 4 Centerville MA 02632 - -216 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately effLOJ 1 . -,79 , 3 -P- 13 34 d i ep ,I ar 6 - -G c26> t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 124 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 1 of 2 Front System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Ca'sse Owner Owner's Name a} information is required for every Centerville MA 02632 4-2-16 = page. City/Town State Zip Code Date of Inspection M tJ1 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 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 F er-Evat a Local Approving Authority 4-2-16 . spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner .,,. Owner's Name information isr required for eve ry Centerville MA 02632 4-2-16 page. ti.,, City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑•ND (Explain below): ❑ obstruction is-removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑' N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspec5on Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking waters upply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms 330 t5ins•3113 Tdie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? 1 ❑ Yes ® No Last date of occupancy: 4-2016 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310.CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is Centerville MA 02632 4-2-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/To'nn► State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'°r 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 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.): Leach pit in good condition and holding water at 12"with stain line at 36" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM , 1 e 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is Centerville MA 02632 4-2-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately zr3 - Pit r1-4 p c- a' l- 3V, filqo , t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is required for every Centerville MA 02632 4-2-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation based on front system install. No groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (System 2 of 2 Back System) Property Address Rose-Marie Caisse Owner Owner's Name information is Centerville MA 02632 4-2-16 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr 3 Company Address �- E. Falmouth MA n 02536 City/Town State Zip Code" `71 1-508-495-0905 S13971 =� Telephone Number License Number B. Certification _ - rl 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 Furth Evaluation by the Local Approving Authority 10-31-11 Inspector's Signature Date The system inspector shall submit•a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ -Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ' 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N , ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N '❑ ND (Explain below): f ' ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed - ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health:,, ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment: 1. System will pass unless Board of Health determines.in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ - The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No 4, ❑ ® !Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 1/day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 11 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system,owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. y 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 ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection 'Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'w 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [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)): 434gpd/2yrs Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Town--not since new in 2008 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) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (f known) and source of information: 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18 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: 1000 gal Sludge depth: 10" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments note if box is level and distribution to outlets equal, an evidence of solids carryover, an ( � � Y rY Y evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O 0 -D�.3�6 �D� �3G _ • A .26 � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: You must describe how you established the high ground water elevation: Original design plans show no groundwater 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Front system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 117 �C) Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityfrown 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-31-11 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner. and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless,Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I N Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) i Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water Y P supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is Centerville MA 02632 10-31-11 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts N f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 434gpd/2yrs g ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 Zi Cit frown State page. Y p Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NIA 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) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M y 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) A Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12" 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 6 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate), ❑ Yes ❑ No Dimensions: 1500 gal 12" Sludge depth: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 1 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 A S" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign.of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31.-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons ` Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 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.): Leach pit in good condition and empty at inspection with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration . Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 'r 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately act G e� Gf n 5> A o z A__0-301 r t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: You must describe how you established the high ground water elevation: Original design plans for front system show no groundwater at 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-1 M0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Thistle Dr (Back system) Property Address Aidian Walsh Owner Owner's Name information is required for every Centerville MA 02632 10-31-11 page. City(rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Iq I' l d '6 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town'of Barnstante yP�oFt"E Regulatory Services Thomas F. Geiler, Director * BARNSTABLE, "`ASS- 1639• Public Health Division �� �ptFD MP'�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Fax: 508-790-6304 Office: 508-862-4644 May 22, 2007 Mr Harvey Gladstone 50 Thistle Drive Centerville, MA 02632 The septic stem located at 50 Thistle Drive, Centerville, MA was last inspected on p y inspector for the State of cn certified septic 7 b James M. Ford, a certif p March 26 , 200 , y Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines ( of 1995 TITLE 5 ( 310 CMR 15.00) due to the following: g Back up of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health l CQ�)�fsor C,�— Town of Barnstable OF tHE Tp� o Regulatory Services Thomas F. Geiler, Director BARNSTABLE, 9 MASS. O �A 1639• 0.�0 Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 16, 2007 Mr. Harvey Gladstone 50 Thistle Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 50 Thistle Drive,(Front system), Centerville, MA was last inspected on March 26th, 2007,by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Back up of sewage into facility or system component due to overloaded or clogged SAS or cesspool You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT J Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health t Town of Barnstable P# Department of Regulatory Services ttnatvarner� r Public Health Division Date sue. A 161 200 Main Street,Hyannis MA 0260.1 .r Date Scheduled " - '®°Z Time Fee Pd._ l/ Soil Suitability Assessment for S age Disposal ' Performed By: NVIb �pUGHA-Wow R 2! 7 Witnessed By: i� LOCATION& ENERAL INFORMATION Location Address S (fie i J ' ° Owner's Name / p GJ� T CC Ul`�Cf lJ P Address Ass essor'sMap/Parcel.• ( /�S �� , / Engineer's Name di 6g0VW/' NEW CONSTRUCPION 6 ` REPAIR V Telephone# Land Use. �dP 0 fie' ii Slopes(`�) 0 Surface Stones Distances from: Open Water Body l O� ft Possible Wet.Area ' ft Drinking Water Well L&O't ft Drainage Way So ft Property Line l 6 t ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands I'n proximity to holes) Z W W J-i i \ Wm �� E < j \ F— W m o / I CO Jz0 LO m I III N N O i—m° q3 lriv m ❑O� 3 W W z3Z O f— �0 1 R J I; F— OOZ OW ❑ w0 �-� w zW / I? CD Ir i—3 L�U i—i— % 00< U ° D❑ l Z wN1[t— WO ZZzO°OO ; L of X<Ln col W CD Parent material(geologic) 5 Depth to Bedrock A b e Depth to Groundwater. Standing Water in Hole: �\o h e Weeping from Pit Face A6 11 Estimated Seasonal High Groundwater S f e Gl e DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: S 42 f ellbo V-P, Depth Observed standing in obs.hole: in. Depth to soil mottles: in, Depth to weeping from side of.obs.hole: in, Groundwater Adjustment..- ft. Index Well# Reading Date: Index Well level Adj.factor— Adj.ChwundwaterLevel,,,e PERCOLATION TEST Date'3"ft Time tl AM Observation h Hole# Time at 4" Depth of Perc P n Time at 6" Start Pre-soak Time C� �q `` i o Time(9"•6") �G y End Pre-soak 1 I' " 2-5 Rate MinAnch -lop; Site Suitability Assessment: Site Passed t/ Site Failed: Additional Testing Needed(Y/N) ' � O Original: Public Health Division Observation Hole Data To Be Completed on Back----------- > - ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC SOIL TEST LOG DATE OF TEST: MARCH 26. 2008 APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. PERC NUMBER: 12153 t TEST PIT 1 NO GROUNDWATER ENCOUNTERED PARENT MATERIAL: PROGLACIAL OUTWASH PERC AT 68 in - 2 MIN/INCH IN C SOILS EI E� ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 62.90 0-12 Ap LOAM 10 YR 3/3 NONE FRIABLE 60.40 12-30 B LOAMY SAND 10 YR 4/6 NONE LOOSE 30-132 C MEDUIM SAND 10 YR 5/4 NONE LOOSE 51.90 NO TEST PIT 2 PAARENOTUNDWATEMAATERI R EPROGLACA LED OUTWASH 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING f 62.90 0-10 Ap LOAM 10 YR 3/3 NONE FRIABLE 60.40 10-30 B LOAMY SAND 10 YR 4/4 NONE LOOSE 30-132 C MEDUIM SAND 10 YR 5/4 NONE LOOSE 51.90 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ns' n Flood.Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No ✓, Yes --1 Within 100 year flood boundary No ✓ Yes Depth of Natura0v®cctarrinz Pervious Material. Does at least four.feet of naturally occurring pervious material exist in all areas observed throughout the 1, area proposed for the soil absorption system? S - - If not,what is the depth of naturally occurring pervious material? - Certification o y q q u _ I certify that on (date)I have passed the soil evaluator examination approved by the _ Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and xperienc(e�described in 310 CNM� 15.t0�117. L. Date `_`a�a'1 2� [.v d V ASH of MgSs Signature q_ MID cy� � m o D. a COUGHANOM, Q:\.SEPTK.IPERCFORM.DOC 00�1 CENSS OQ C FVALUP' TOWN OF BARNSTABLE LOCATION SD —rt,sf-te 6, SEWAGE# 0O0' 1a S VILLAGE (eAh y,I Le, ASSESSOR'S MAP&PARCEL 1 (o T- IN.STALLERS,NAME&PHONE NO. z, —• r; 2a6 ia:scx SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) a 9 S60 (size) a 3-S y )3 x a NO.OF BEDROOMS 3 OWNER PERMIT DATE: 1 COMPLIANCE DATE: `O k Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility a°��_ 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 be-s o q,,, 014,E d44,e,,I- 3/37/d 7 7FI T- ,f� TAlul -30 0-8d/ 6-3 r Ici 5A s No. Q Fee THE COMMONWEALTH OF MASSA CHUSETTS Entered in computer: PUBLIC HEALTH DIVISION'-= TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYicatiou for �DiOpotal *pgtem Cougtructiou Permit Application for a Permit to Construct( ) Repair Y4 Upgrade( Abandon( ❑ Complete System Y Individual Components Location A dress or Lot No. �� ,T `O_w',ner''ss,Name,Address,and Tel.No.5dV_��� Assessor's Map/Parcel St +�0_ 16 -� 5o8-��s-g�� 5og-3(oy- o xqy Installer's Name,Address,and Tel.No. Designer's Name,Ad ess and Tel.No. ink Z06r\so� SIr. SCIP+�G CC TP�`'� © vtkLe— Type of Building: 2 Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1?0 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description o Soi L S W1 Nature of Repa rs or Alterations a lic � rw 111 e, S SAS 40 Icy 'E60- Q.0 , # cat-agga Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea h. Signed Date 3 7- - 6 Application Approved by Date Application Disapproved by: Date for the following reasons I)d 1 z.� , Permit No. S Date Issued ,3'-���''� N0. dt�d �" ' _ y Fee " 1 } 1/ Entered in computer: THE COMMONWEALTH OF MASS�CF�USETTS PUBLIC HEALTH DIVISaIOIV•=?OWN OF BARNSTABLE, MASSACHUSETTS Yes r 2pprication for Migpogal 6pgtem Construction Permit . Application for a Permit to•Construct O Repair Upgrade( ) Abandon O ❑ Complete System Individual Components O • Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 50�-3�y- og�y Installer's Name,Address,and Tel.No. D igner's Name,Address and Tel.No. tA� Z. 0,�_ _H C c, e Ecx LDRq C` v i lam. y3 �� ��G rcJe ,SC ,d�I Type of Building: r Dwelling No.of Bedrooms, f f Lot Size sq.ft., Garbage Grinder (Y)p Other Type of Building :—£ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow-'(min required) 370 gpd Design flow provided 1 gpd Plan.,-Date Number of sheets Revision Date .f Title Size of Septic Tank Type of S.A.S. Description of So' Nature of Repairs or Alterations r�swe>_w en a licab ) C ��J �i ��� S 'Q'2P� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title"5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea th. Signed ..,.•- Date 3 ,;L g IJ l Application'Approved by �,� Date 7 ^ ? G Application Disapproved by: Date for the following reasons Permit No. d 00 { Date Issued 3"",.)9"'O$' THE COMMONWEALTH OF MASSACHUSETTS, BARNSTABLE, MASSACHUSETTS (Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by O rh E 12�b i.1nrn S Lk(_`J� � t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. :�,0oe— I dated 3,",2.k a Installer Designer #bedrooms Approved design flow ?d gpd The issuance of thGis�perm't shall not be construed as a guarantee that the syste/11"W—ill fu ctp"'<n a designed. Date ("�� Inspectors —-----^--'� No. U d a Feeb )w THE COMMONWEALTH OF MASSACHUSETTS x PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS G-I�s Migogal *pgtem Cottgtruction Permit Permission is hereby granted to Construct ( ) Repair (�( )`,, Upgrade ( ) Abandon ( ) System located at�� ��ISM 1�C� oe , Q �t4 U► ,�e_ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of ylrts pe i .. Date�/1Z/UO Approved by Town of Barnstable �F fHE.j "o Regulatory Services Thomas F. Geiler,Director. MAW. Public,.�' Public_Health°Division ArF Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification.Form Date: Sewage Permit# ( Assessor's Map\Parcel 5 Designer: �C� - Installer: Address: 3 I (�►� �(� f'C� Address: 1�O \0,�q SaYn6 UO' � I Dfv\ �( inSlM qP was issued a permit to install a (date) (installer) septic system at Q:" S� Ir� based on"a design drawn by (address) CPS V dated (designer) r I"certify that the septic system.referenced above was installed substantially according to the design, which may include.minor approved changes.such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. K greater than 1:0' lateral relocation of the SAS or any vertical relocation of any component of the septic system)`but in`accordance with State&'Local Regulations: Plan revision or certified as-built by designer to follow. DAVID (Installer's Signature) COUGHANpWR N No. 1093 G/s re��� SgNf TARIP� (Designer's:.Signature) (Affix Design p Here) PLEASE RETURN TO :BARNSTABLE PUBLIC .HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE: ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD. ARE RECEIVED BY THE BARNST.ABLE"PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3 26.-04:doc Town of Barnstable GF tHE 1p� do Regulatory Services ns Thomas F. Geiler,Director 039. � Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 16, 2007 Mr. Harvey Gladstone 50 Thistle Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 50 Thistle Drive,(Front system), Centerville, MA was last inspected on March 261h, 2007,by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed" under the guidelines of 1995 TITLE 5 ( 310 CMR 15.00) due to the following: Back up of sewage into facility or system component due to overloaded or clogged SAS or cesspool You have 60 days from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT s 4 Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health y U9COMMONWEALTH 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: 50 Thistle Drive 2 SYSTEMS Centerville, MA 02632 Owner's Name: Harvey Gladstone L/ A�,(� Owner's Address: 7� Date of Inspection: _ March 26, 2007 Name of Inspector: (Please Print) James M. Ford Company Name: James M. For ll Mailing Address: P.O.Box 49 Osterville AM 02655-0049 Telephone Number: (508)862-9406 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. Ilam a DE approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes (backyard) Conditionally Passes l O Needs Further Evaluation by the Local Approving Auth =f ✓ FaA (front yard) Es; Inspector's Signature: Date: A ri14 2007 O The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of alth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow o 10,000 gpd or greater,the inspector and the system gwner 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: SO Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓(back systeni) 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. t determined Y N ND in the for the following statements. If"not determined",please Answer yes,no or no ( ) g 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: 50 Thistle Drive Centerville, AM Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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 aseptic 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 colifonn 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 PART A CERTIFICATION (continued) Property Address: 50 Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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 'h 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 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.] Yes (rout system) (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 I Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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: 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 i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: SO Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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: 2 Does residence have.a garbage grinder(yes or no): Yes 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: Never pumped-per owner(front system is on final) 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 1(2) 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: Front was original-back was installed in 1987(per as built card) Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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: 12"(front) - 5"(back) 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 gal. (front) - 1500 kal. (back) Sludge depth: 10"(front) - 2"(back) Distance from top of sludge to bottom of outlet tee or baffle: 20"(front) - 30"(back) Scum thickness: 12"(front) 5"(back) Distance from top of scum to top of outlet tee or baffle: 4"(front) - 6"(back) Distance from bottom of scum to bottom of outlet tee or baffle: 10"(front) - 10"(back) 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.): The front system had baffles. Recommend pump. The back system had cement tees. 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: Connnents(on pumping recommmendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 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: ✓(back) (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 back system had a D-box. The D-box was normal with no solids present. 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: SO Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,.dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): a The leach pit for the front system was full. The liquid level was up to the inlet pipe The front bit was in failure The leach pit in the back had 4.5'of liquid on the bottom. The scum line was at the sane level. There did not appear to be any signs offailure. 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 J Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) _........ - Property Address: SO Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March`26, 200.7 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmark. Lncate all well.within 100 feet Locate where public water supply enters the building GAC f— 1>00e, A B 0 3- a5 a a� 30 CJAU O a l3 03 as lc� a 3o 3 3Y 39 'fo y3 10 i a Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Thistle Drive Centerville, MA Owner: Harvey Gladstone Date of Inspection: March 26, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- 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 maps were showing approximately 30'+/--to ground water at this site This report has been prepared only for the septic system and components described herein. This septic system has been inspected 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 TOWN OF BARNSTABLE Fr'Lh"'1+ LOCATION f S 7/Q SEWAGE # VILLAGE C_G�n, A-eN'(/ �� ASSESSOR`S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J OM/ --�— LEACHING FACRM: (type) L e-l'S (size) _SDO 'S NO.OF'BEDROOMS__3 BUILDER OR OWNER pERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 4 Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any Walls exist on site or within 200 feet of le=hing fw-iility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of hung factli } Feet Furnished by .A a 1 - Ac o(f-31 Li �10 r- 3q' / 1TOWN OF BARNSTABLE LOCH T ION - SD Th S >7 � SEWAGE # _ VtI!I:AGE Z6�e- a- `� ASSESSOR'S MAP&LOT INSTALLER'S NAMF-&PHONE NO- SEPTIC TANK-CAPACITY r;�1 LEACHING.FACIiL.YW' {type} Ip ] (size) � � `o. el NO.OF BEDROOMS _ j3UILDER OR OWNER PBRMrrDATE: _ - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Fu lity (If any swells exist on site or vAttun 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 act F oD -c- 311` j>q ' Llo F J? r k.. S sr �L Y OWN OF BARNSTABLE LOCATION SO 7r SEWAGE# VILLAGE CQA-rVV kU, l ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY T�'W LEACHING FACILITY.(type) 40c 7 NO.OF BEDROOMS 3 J OWNER G/AC ST tit. PERMIT DATE: PLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY:1✓ Sp&,,- Fp(�. t aA (3 1 G1asS A' > O a a 03 a 3o aco Y 3 3Y 39 LOCATION SEWAGE PERMIT NO. 'NiSTLE 02,.vo -VILLAGE INSTALLER'S NAME&ADDRESS 46= Due, CD I--I 6,Q-W i c N . Nt) . BUILDER OR OWNER ua,2uf2e QoLo 5Towe 50 TU( STLE D"VE Ce l_LfW(U C DATE PERMIT ISSUED DATE COMPLIANCE ISSUED e6 7 PIMP cuss � LL 39 3� LL f - , 7 �- a IVo...-�• -�-- F$$....�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ---- - I WM..............OF.........104WTtp6 re.---...---.............----...-...... 1�1- V�6 Applira#ion for Disposal Worku Tonotrurtivn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .J a '01h.3........ .. .t .L..G........._Dtux..................CeA.. r..wA 11 �, .......... . ... O ..Local' Address or ..............................,. . ... ....... Lo o. � /a'1 ,�.. ... i� 44 m, s..........- �.L......... ........ �F,l���,l ....... ... red-c............................. a .............. . C bE>.S.-----..D.'a I@. A. ........................... l '- � , ��f A .................................... Installer Address UType of Building Size Lot.__.,/,_.!��?.._.....Sq. feet Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) per.,, Other—Type of Building _1 Siov--1n1_.d_.. No. of persons............4.............. Showers ( ) — Cafeteria ( ) a' Other fixtures ...............................................••-_.... W Design Flow............................................gallons per person per day. Total daily flow...........3«._._._........_.......gallons. WSeptic Tank—Liquid capacity/.-gallons Length................ Width................ Diameter................ Depth................. Disposal Trench—No..................... W%7------------------ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.._.__!_®_t�9.... Diameter.�._..__.pw_bb pth below inlet.................... Total leaching area...3�a�.__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G>~ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....................................... ....... ------------------- •------------------------------- ------------------- .... -...... ............ ---.----------- O Description of Soil......... ............. x W ---------------------------•--•---------•-•----••-•••------•-•------------••--••...•••-••••----•-••-...•--•••••---_.._..•-----------•••---••••------•--••••----•--••••••••-•••......-------••-•--•----- U Nature of Repairs or Alterations—Answer when applicable..-_............................................................................................ •-••----•----•--••-••--•••••-•••...............•••-----•-----•••-••••--------...••--•-••---......•-•-••---.-_..._.....---•----••---•--•••--•-...............--•-•-•-••••-•--•-•••••••--•-••............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Di osal System in accordance with the provisions of Article XI of the State Sanitary Code— undersigned fur er a rees not to place the system in operation until a Certificate of Compliance has been issue the boar h th. r Signed.. ......... . ••............... ... .. Date ApplicationApproved By.....................•......................................................................... Date Application Disapproved for the following reasons---------------------- ------•---•------------------•-----------•--------•---...........-••-•-......•--•----- ------------------------------------- ---------------------- --------- •••-------- ---- ------------------------------------------------ ------------------------- ------------.-.-.--- Date PermitNo......................................................... Issued....... S Z�.............. ate -33,9, FEim .............No......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH .......... .... ....... OF......... 01o9!vkjJ'.- ...................................... . Applirativit for Biopmal 18orko Tonotrurtion rumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 40' .1 ........... ........1,4.0w...............tom.... ..0-i.........;........TZLj.k.'C�.................. ................................................. Locat* •Addr ess or Lot No ........ . ................................ ........................ e ................................ . Add ...............Tz�,sa ........................... ..E .(...... ........ .................................. Installer Address Type of Building Size Lot.....Zd..g ?........Sq. feet U Dwelling—No. of Bedrooms................ue,.......................Expansion Attic Garbage Grinder a Other—Type of Building .115S.6.--,.��I...w..9'... No. of persons............t.............. Showers Cafeteria Other fixtures ....................................................... W ................................................................................................ Design Flow.............................................gallons per person per day. Total daily flow...........3.JtO......................gallons. P4 Septic Tank—Liquid capacity./M. ._.gallons Length................ Width................ Diameter:............... Depth................ Disposal Trench—No_.................... Width ..... ..... Total Length..............._.... Total leaching area....................sq. f t. Seepage Pit No...'.....:';,;_-..-.. Diameter........... ,c,.kT)epth below inlet.................... Total leaching area....IJO.A..sq. ft. Z Other Distribution box, Dosing tank Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit......._........._.. Depth to ground water-..-------..-_------.-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.....--............. Depth to ground water.........._...---_-..--. .......... *------..........91"...y... ' ....**----------*****.......*-------------------- ........*--------------------*,-"*,*,*,,*---------- 0 Description of Soil......... i! t . A i l.................................................................................................................. U ................................. ...................m................................................................................................................................................... W Z ...................................................... ............................................................................................................................................... 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 &Article XI 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...................................................................................... ................................ Date ApplicationApproved By ........................................... ................................................ ..................... .................. Date Application Disapproved for the following reasons:............................................................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued.---------..._..`/,�e . .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............�­!?��?y........OF............ / ............................... %Trruftrate of Tjoutphatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by........ L..........:2o. ................................................................................................................................. Installer /'.L at........(n�0.7" tZ .............. .... ........... e J.�--------------_------------------------------------------- .................................. has been installed in accordance with the provisions of Article XI 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 CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE......................... Inspector................ 7 /7• ­�'­­------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ OF............ A/i............ ...................... ............................ No................I........ FEE....................... Disposal Works ouptrurtion ranfit Permission is hereby granted........ .......... ....... ............................................................................. to Construct �r R em epair )-an Individual Sewne.Disposal yst r 3 ......... ................ .4';>;'j tf ( at No.......... ............................. ... Street as shown on the application for Disposal Woriks ConstructionP 't No....................I.—E Per N lated.... . .............. Al ......................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS CONTOURS _ BENCH MARK ( �S EXISTING - - - - - - - 50 ti11 l NAIL IN ROAD t GARBAGE GRINDER MINIMAL GRAD_IrWG PROPOSED N °Rf� ELEVATION = 61.00 IS NOT ALLOWED ` ��� p -E- BARNSTABLE GIS DATUM WITH THIS DESIGN. o o� e f ti 0 w 000>_ 63 °R �F ��� , I-Q-1 1 138.28 f f LOCUS m J m m 1 t 63 CENTERVILLE. MA LbCON ETE t --- LOCUS MAP d I DRI V GM y w>< J 1 NOT TO SCALE mw G 1 / I mT-z zcr;` �7 1 1 oTU� ;:::.: ow f=XIS0� w �, 1%Ar Ln w X TING EXISTING SEPTIC SYSTEM I LEGEND o° Ewo c 0 w W �'°z TITER LI� � ;. B DR 1 J z❑ J z -, w °o OOM 1 EXISTING �z m w I r cwn Ul J �--� W W I C�WE • 1000 G/�L L ON PASSED TIT E 5 _ W LU z 4 O L IIVG SEPTIC TANK �w W} U � � � m o� O{� ' 7-0 1 cn _j I P 1 EXISTING LEACH p <cwn x a z N = ci 2 -o EL = 64. FA/DA/ PIT/CESSPOOL • (Dz m m< W < w W Z 54 — j O V D W 1 TP-2 N W w cn I 1 I 1 UTILITY POLE WT o zQ w 4 1� z Q W � ow m " w m I® O r� TEST PIT ® D-BOX D CD :.:r:,:.::.: W O J < (p }:»:+rrr: � 1 20-0 I z e Z J c� 1 I DECIDUOUS CONIFEROUS W LL o J X N I �I I T -1 } TREE �qOp� TREE ,� w z p m m �J 1 d�}b 12-M 12-P Z N (n w� M m ((7 Lr)- O i 15-0 O ff;B r 1 INCHES. LETTER DENOTES REFERS TO ETYPE.TER IN ~ w UJLID O T 163 W ZI = L� 0 U W / ;a U7 O-OAK M-MAPLE P-PINE C-CEDAR UF- U �0 V 1 I (Zu Gi w Z J 1 i f'(REA 15006 s f = Ill a� x ow zw O �� cn UZ c�Q wZ E �fMa�MgSS o DAVID e � to t <O ~ CL m CO Ul 0� G S O 'P -�.� � 9cyGs ��ZN OF MgS. 3 z Z IC LINE �— �o DAVID GN D. w ,, I o 1 -o --� - COUGHANOM % D. WO Z.. I ___�-- a � 3 ? LO m I __�__�-- 160.68 Ft s3 No. 1093 COUGHANOVII o 6W > LA N 1 ��� �G1ST `rp l/CE 3' 0 J O cmo X _ J X U w 63 V A `/ ew w 23.51f, x1283 FL x2 FL Z7 m W LEAC,�HING GALLERY ®a �� SEWAGE DISPOSAL SYSTEM PLAN Z J 0 z �� fey -TO SERVE EXISTING DWELLING J z J FLAN EST. HARVEY M. GLADSTONE LL ~ o f CD m U SCALE: t i n = 20 Ft � NOTES 0 �� OWNER OF RECORD 0 z o w (n (� ,_, EXISTING LEACH PIT IS TO BE PUMPED. TO 50 THISTLE DRIVE ry O II m X I— 20 0 20 40 ALLLASSO�ATED REMOVED. CONTAMINATED SOILS � 1995 �� CENTERVILLE. MA f1 e I w W 0 10 z0 AND REPLACE WITH CLEAN MEDIUM /�®N��� PROPERTY ADDRESS n 0 + 9 SAND PER TITLE 5. Z .� CIS ASSESSORS MAP 171 PARCEL 6 5 L A 40 MIL POLYETHYLENE LINER IS TO 43 TRIANGLE CIRCLE 3 VARIANCE REQUESTED BE INSTALLED BETWEEN LEACHING SANDWICH MA 02563 PLAN BOOK 247 PAGE 84 GALLERY AND DWELLING FOUNDATION. 506 364—m894 0 Q �� z Z F MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT OR HEALTH INSPECTOR. DATE MARCH 27. 2008 J m ECO-TECH RECOMMENDS SHUTTING OFF JOB # E T E-2 8 8 2 PAGE I OF 2 VERSION: J p W w W W 31P1 CMR 15.211(1) - SOIL ABSORPTION THE GAS SERVICE TO THE DWELLING THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED LL SYSTEM TO CELLAR WALL. 20 ft MIN AND CAREFULLY DIGGING BY HAND IN SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM REQUIRED - VARIANCE TO 8 ft THE VICINITY OF THE GAS LINE. DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING SEPARA TION REQUESTED. PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS. OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOIL TEST LOG DESIGN CALCULATIONS _ :. DATE OF TEST: MARCH 26. 2008 r DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL PERC NUMBER: 12153 CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) TEST PIT 1 NO GROUNDWATER ENCOUNTERED DISTRIBUTION BOX: USE 3 OUTLET D-BOX. PARENT MATERIAL: PROGLACIAL OUTWASH SOIL ABSORBTION SYSTEM: A '23.5 Ft x 12.83 Ft x 2 Ft LEACHING GALLERY CAN LEACH PERC AT 68 In - 2 MIN/INCH IN C SOILS Abot = ( 23.5 x 12.63 ) = 301.5 sF ELEVATION Asdw = ( 23.5 + 23.5+ 12.B3 + 12.B3 ) x 2 = 145.3 sf DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER Atot = 446.8 sf 62.90 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Vt 0.74 x 446.8 = 330.6 GPD 0-12 Ap LOAM 10 YR 3/3 NONE FRIABLE USE A 23.5 Ft x 12.83 Ft x 2 Ft GALLERY. Vt. = 330.6 GPD > 330 GPD REQUIRED 60.40 12-30 B LOAMY SAND 10 YR 4/6 NONE LOOSE 51.90 30-132 1 C MEDUIM SAND 10 YR 5/4 1 NONE ILOOSE �] LEA CHING GALLERY 1000 GALLON SEPTIC THINK TEST PIT 2 PAARENOTUMAATERIARL ENCOUNTERED OUTWASH USE SHOREY PRECAST 500 GALLON NOT TO DIMENSIONS AND DETAIL NOT TO 2 MIN/INCH IN C SOILS LEACHING DRYWELL (H-10 LOADING) SCALE USE EXISTING H-10 LWIT SCALE SEPTIC TANK IS TO BE PUMPED DRY ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER CONSTRUCTION DETAIL AT TIME OF INSTALLATION AND IS TO (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING BE EXAMINED FOR STRUCTURAL 62.90 DRYWELL UNIT STON INTEGRITY. INSTALL NEW PVC OUTLET 0-10 Ap LOAM 10 YR 3/3 NONE FRIABLE 23.5 Ft TEE EQUIPPED WITH A GAS BAFFLE. 60.40 10-30 B LOAMY SAND 10 YR 4/4 NONE LOOSE � 1 In 30-132 C MEDUIM SAND 10 YR 5/4 NONE LOOSE 4- IT Ti:2 51.90 m "'L m40GROUNDWATER ADJUSTMENT c 4 �EXISTING GROUNDWATER LEVELBASED ON TOWN OF BARNSTABLE 3.25 F 8.5 Ft 8.5 ft .25 ft LGIS DEPARTMENT RECORDS. 23.5 Ft .%INDICATED GW 35.00 ��'INDEX WELL SDW-252 Q ZO NE E D 500 GALLON DRYWELL READING DATE FEB. 2006 DIMENSIONS AND DETAIL READING 47.4 OVER OUTLET ADJUSTMENT 3.6 ADJUSTED GW 38.B USE l-I-10 UNIT INSTALL ONE INSPECTION RISER TO WITHIN THREE -� AIN DROP Al� FLOW LINE INCHES OF FINAL GRADE FROM AND INDICATE LOCATION BUILDING 10 In 14 TO ON AS-BUILT PLAN in D-BOX 48 in LIQUID GAS s LEVEL BAFFLE N Q_T E .S. 0 33 In 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. �oo�000 ooa00000000 000 CROSS SECTION VIEW 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED o000000a000 00 FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS 1021ij OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES CROSS SECTION VIEW BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND REMOVED. 2 to PEASTONE 2 in PEASTONE SEWAGE DISPOSAL SYSTEM PLAN 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. o o -TO SERVE EXISTING DWELLING 7) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES 28 3i4,n ro FECTIVE 4,n ro [2��AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. 1n �-��^�^"�- DEPTH 1-��^�A�EL n HARVEY M. GLADSTONE Bl SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT 50 THISTLE DRIVE CENTERVILLE. MA PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 46 In 58 in 46 in 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 1501n ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. FABRIC IN PLACE OF THE 2 In. PEASTONE LAYER SPECIFIED. ETE-2882 MARCH 2�. 2006 212