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HomeMy WebLinkAbout0040 THREE PONDS DRIVE - Health 40 THREE PONDS DR., CENTERVILLE A= 193 184 i ^`lll�Z�[LC� G PC 12543 0 No. q �NST•CON`'�y HASTINGS,61F1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Three Ponds Dr. :+ Property Address ; Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 T' required for every � page. City/Town State Zip Code Date of Inspection .Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:out forms A. Inspector Information s1t. /8g�$ filling out forms on the computer, use only the tab Thomas Roux key to move your Name of Inspector cursor-do not use the return Company Name key. 89 Mayflower Lane VQ Company Address East Wareham Ma. 02538 AA Citylrown State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4� 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every Y page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"ConditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Y Centerville Ma. 02632 May 18 2019 required for every , page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ON ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -.� 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every Y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Y Centerville Ma. 02632 May 18 2019 required for every , page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El i ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 40 Three Ponds Dr. V Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18, 2019 required for every y page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form � F i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments H 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Y Centerville Ma. 02632 May 18 2019 required for every , page. City(rown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): No Design Number of bedrooms(actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): +330 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? E Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18, 2019 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): septic tank and single pit. Approximate age of all components, date installed (if known)and source of information: 39 years, House was built in 1980. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3.8 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Y Centerville Ma. 02632 May 18 2019 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.8 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: 81 x 5.67'W x 5.67'H Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 23" 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 24" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is in good condition. The inlet and outlet septic tank covers were both replaced with new covers. Risers were also installed to bring the covers closer to finished grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts fe - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Y Centerville Ma. 02632 May 18 2019 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f v 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is y Centerville Ma. 02632 May 18 2019 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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 system was dug up with an excavator. There was no D-Box found. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Y ille Ma. 02632 May 18 2019 requiredd for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: The pit structure was dug up and inspected. The pit structure is 6 ft. tall. The structure had 5 inches of water in it, at the time of the inspection. A riser was installed for the pit so as to bring the cover closer to finished grade. The pit is not in the groundwater. Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 40 Three Ponds Dr. Property Address Stephen& Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18, 2019 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18, 2019 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �a 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ry I i I cf_"C-� C' t fco i a �400 ® 41, � +0 T. ,n Ato . �_ o �t33, c t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: below 10.2' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A soil evaluation was done as part of the inspection. See attached soil evaluation report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . � 40 Three Ponds Dr. Property Address Stephen & Diane Dasti Owner Owner's Name information is Centerville Ma. 02632 May 18 2019 required for every y page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•'rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts City/Town of Centerville Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Stephen & Diane Dasti Owner Name 40 3 Ponds Dr. Street Address Map/Lot# Centerville Ma. 02632 City State Zip Code B. Site Information 1. (Check one) ❑ New Construction ❑ Upgrade ❑ Repair 2. Soil Survey Available? ® Yes ❑ No If yes: Website 252D Source Soil Map Unit Carver Coarse Sand Soil Name Soil Limitations Sandy Glaciofluvial Deposits Ice-Contact Slopes Soil Parent material Landform 3. Surficial Geological Report Available? ❑ Yes❑ No If yes: Year Published/Source Map Unit Description of Geologic Map Unit: 4. Flood Rate Insurance Map Within a regulatory floodway? ❑ Yes ® No 5. Within a velocity zone? ❑ Yes ® No If yes, MassGIS Wetland Data Layer: 6. Within a Mapped Wetland Area? El Yes ® No Wetland Type 7. Current Water Resource Conditions (USGS): Range: ❑ Above Normal ❑ Normal ❑ Below Normal Month/Day/Year 8. Other references reviewed: t5forml 1 3.Ponds•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 5 Commonwealth of Massachusetts City/Town of Centerville Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: DTH-1 May 18, 2019 3:30 P.M. overcast Hole# Date Time Weather Latitude Lonqitude: residential none gravel 15-35% 1. Land Use (e.g.,woodland,agricultural field,vacant lot,etc.) Vegetation Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%) Description of Location: 2. Soil Parent Material: Sandy Glaciofluvial Deposits Ice-Contact Slopes Landform Position on Landscape(SU,SH,BS, FS,TS) 3. Distances from: Open Water Body +100' feet Drainage Way +50' feet Wetlands +100' feet Property Line +20' feet Drinking Water Well +100' feet Other feet 4. Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed:❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Redoximorphic Features Coarse Fragments Soil Soil Horizon Soil Texture Soil Matrix:Color- /°by Volume Depth(in) /Layer (USDA Moist(Munsell) Cobbles 8 Soil Structure Consistence Other Depth Color Percent Gravel Stones (Moist) Fill 19"-122" C Med./Coarse 2.5Y7/4 Sand Additional Notes: t5forml 1 3 Ponds•rev.3/15/18 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 5 Commonwealth of Massachusetts = City/Town of Centerville y` Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: Hole# Date Time Weather Latitude Longitude: 1. Land Use: g ) g ( g ) Slope( ) (e.g.,woodland,agricultural field,vacant lot,etc. Vegetation Surface Stones e. cobbles,stones,boulders,etc. Description of Location: 2. Soil Parent Material: Landform Position on Landscape(SU,SH,BS,FS,TS) 3. Distances from: Open Water Body feet Drainage Way feet Wetlands feet Property Line feet Drinking Water Well feet Other feet 4. Unsuitable Materials Present: ❑ Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed:❑ Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole Soil Log Coarse Fragments Soil Horizon Soil Texture Soil Matrix: Redoximorphic Features °/° Soil Depth(in) by Volume Soil Structure Consistence Other /Layer (USDA) Color-Moist Cobbles& (Munsell) Depth Color Percent Gravel Stones (Moist) Additional Notes: t5forml 1 Ponds-rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 5 3 Y 9 Commonwealth of Massachusetts City/Town of Centerville Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: Obs. Hole# Obs. Hole# ❑ Depth observed standing water in observation hole inches inches ❑ Depth weeping from side of observation hole inches inches ❑ Depth to soil redoximorphic features (mottles) inches inches ❑ Depth to adjusted seasonal high groundwater(Sh) inches inches (USGS methodology) Index Well Number Reading Date Sh= Sc—[Sr x(OWE—OW,r,ax)/OWrl Obs. HoleNVell# SC Sr OWE OWmax OWr Sh 2. Estimated Depth to High Groundwater: below 122" inches E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed (exclude A and O Upper boundary: 191, Lower boundary: 122" Horizons)? inches inches c. If no, at what depth was impervious material observed? Upper boundary: Lower boundary: inches inches t5form11 3 Ponds•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 5 Commonwealth of Massachusetts City/Town of Centerville Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. May 18, 2019 Signature of Soil Evaluator Date Thomas Roux/SE2703 June 30, 2019 Typed or Printed Name of Soil Evaluator/License# Expiration Date of License Name of Approving Authority Witness Approving Authority Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing,and to the designer and the property owner with Percolation Test Form 12. Field Diagrams: Use this area for field diagrams: e� I Z ( Q S e- e. T t5form11 3 Ponds•rev.3/15/18 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 5 YS ; y �Y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIROiNMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 �V 5�•" f Louise Gogolos g WILLIAM F.WELD ^ LRUDY COXE Governor G Secretary v,f ARGEO PAUL CELLUCCI �j! DAV1D'B.STRUIIS Lt.GovernorSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F M,Q ��`�� Commissioner PART A, CERTIFICATION T Ro ePoPro art Address: 40 Thr nds Drive , Centery ;6gof Owner: ?Date`of Inspection: P MA (If different) . Name of Inspector: Wm E Robin'son Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Serv; c Mailing Address: PO Box 1089 , C n er r; 1 1 p 0, MA 02632 Telephone Number;' 50 g ` 7 5_R 7 7 6 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewa disposal systems. The system: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: w ky Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI STEM CONDITIONALLY PASSES: I 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. Indica yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health.' (r ed 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Jwww.magnet.state.ma.us/dep t"j Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4.0 Three Ponds Drive , Centerville Owner: Louise G Olos Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box 'is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FUR HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Three Ponds Drive , Centerville Owner: LOuise Gogolos Date of Inspection: D] SYSTEM FAILS: You ust indicate eirr;er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LA E SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requ rements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Three Ponds Drive , Centerville Owner: Louise Gogolos Date of Inspection: S_Q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. ✓/ _ The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. _LZ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. f The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of 1 Sub-Surface Disposal System. v Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) page 4 of 10 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Three Ponds Drive , Centerville Owner: Louise Gogolos Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:�U g.p.d./bedroom for S.A.S. Number of bedrooms: J Number of current residents: Garbage grinder (yes or no):,,!— 0 Laundry connected to system (yes or no): Seasonal use (yes or no): t., 0 Water meter readings, if available (last two (2)year usage (gpd): 1998 30 , 000 gal (6 mos) Sump Pump (yes or no):/f, d ga 1996 34, 000 gal Last date of occupancy: ' C MMERCIAUINDUSTRIAL: Typ of establishment: De n flow: gallons/day Greas trap present: (yes or no)_ Indusjilt: a aste Holding Tank present: (yes or no)_ Non- waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last da e of occupancy: OTHE : (Describe) Last ci of occupancy: GENERAL INFORMATION PUMPING RECORDS d�raurce ole ormatgn: l System pumped as part of inspection: (yes or no)_,,4,0 If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: p Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4b Threge Ponds Brive , 'Centerville Owner: Louise Gog;olos Date of Inspection: /— BUILDING SE R: (Locate on site Ian) Depth below g ade: Material of co struction: _cast iron _40 PVC_other (explain) Distance f m private water supply well or suction line Diamet Comme ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on.site plan) Depth below grade Material of construction: vconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:•°I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .7.:1, , How dimensions were determined: - Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,)ev' ence of leakage, etc.) GR SE TRAP: (locat on site plan) Dept below grade: Mate ial of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Di ensions: Sc m thickness: D stance from top of scum to top of outlet tee or baffle: istance from bottom of scum to bottom of outlet tee or baffle: ate of last pumping: C mments: (re ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural in grity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Three Ponds Drive , Centerville Owner: Louise Gogolos Date of Inspection: J^S -9 `7 TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene—other(explain) Dime sions: Capa ity: gallons Desi n flow: gallons/day Alar level: Alarm in working order_Yes; _ No Dat of previous pumping: Com ents: (cond tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:`" (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evid ce of solids carryover, evidence of leakage into or out of box, etc.) rp`> PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms ' working order (Yes or No) Comm ts: (note ndition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. 40 Three Ponds Drive , Centerville Owner: Louise GOgolos Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,Iength: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, et / d �'a ��t�-C.6 5 f Z..,,,r e��0 x tom" �G� CESS COOLS: _ (locat on site plan) Num rand configuration: Depth-t p of liquid to inlet invert: Depth solids layer: Depth o scum layer: Dimensi ns of cesspool: Materials of construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Comm)dition s: (note c of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI (locate n site plan) Material of construction: Dimensions: Depth o solids- Comme its: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (zevimed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Three Ponds Drive , Centerville Owner: Louise Gogolos Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) FA (revised 04/25/97) Page 9 of 10 - n f �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) • Property Address: 40 Three Ponds Drive , Cemterville Owner: Louise Gogolos c Date of Inspection: ✓ - S=S .k lil Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting., roperty, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) �A i1 (revised 04/25/97) Page 10 of 10 q t g 5 Commonwealth of Massachusetts \ , , , Executive Office of Environmental Affairs Department of `f Environmental Protection Env�ro 1 LFO William F.Weld � yq. Governor �Y 11LOS,� Trudy Coxe 4N a 8eeMary,EOEA David B.Struhs S Comm{abner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 40 3 Ponds Dr Centerville Address of Owner: Date of Inspection: iO '(p — q 6 (If different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT ��77 77 1 certify that I have personally inspected the sewage displ spsUIJit this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _i Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature. ��� y Date: /� C The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: "ve not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why no$ _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 • FAX(617)556.1049 • Telephone(617)292-SM Printed on Racyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Three Ponds DR Centerville Owner: A. Mathews Date of Inspection: j(y — —Lj je' B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM VYILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH ILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRO�'MENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTE FAILS: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 6/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: mg D)SYSTEM FAILS(continued): , Static liqui level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid pth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Requ' ed pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nu r of times pumped A portion of the Soil Absorption System, cesspool or privy is below.the high groundwater elevation. ny portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAILS: /hen riteria apply to large systems in addition to the criteria above: of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety ment because one or more of the following conditions exist: stem is within 400 feet of a surface drinking water supply stem is within 200 feet of a tributary to a surface drinking water supply stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a pc water supply well) . The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: I8-C, "g Check if the following have been done: tlPumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and.the system has been receiving normal flow rams during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A's built plans have been obtained and examined. Note if they are not available with WA. The facility or dwelling was inspected for signs of sewage back-up. } The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. I.system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. //The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _/The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: ®U —L—5 4— FLOW CONDITIONS RESIDENTIAL: Design flow: .3, 0 gallons Number of bedrooms:,? Number of current residents: Garbage grinder(yes or no): A/ Laundry connected to system (yes or no):� Seasonal use (yes or no): 6," Water meter readings, if available: Last date of occupancy:)0—L--c's COMMERCIAUI N DUSTRIAL, Type of establishment: Design flow: s_gallon ay Grease trap present: (yes r no)_ Industrial Waste Ho;ischarged i g Tank present: (yes or no)_ Non-sanitary waste to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)Lt/ If yes, volume pumped. gallons Reason for pumping: TYPE O YSTEM 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: AS '60; / d� S Sewage odors detected when arriving at the site: (yes or no)L✓ (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: SEPTIC TANK:_ (locate on site plan) , t Depth below grade Material of construction: _concrete_metal _FRP—other(explain) Gt ► t Dimensions: I T,1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:3 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 baffler Comments: (recommendation for pumping, condition of inlet and outlet tees or es, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) / (C e 4 ..� GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: ncrete _metal _FRP_other(explain) Dimensions: Scum thickness: Distance from top of sQum to top of outlet tee or baffle: Distance from bottom/ot 5rom to bottom of outlet tee or bafie: Comments: (recommendatio for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidertice of leakage, etc.', (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: TIGHT OR HOLDING TAN (locate on site plan) Depth below grade: Material of construi Co . _concrete _metal _FRP—other(explain) Dimensions: Capacity: >;allons Design flow: allons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: I t Ian (locate on site ) P Depth of liquid level above outlet invert:_ Comments: (note if level and distributiuun is equ-1, evidence of solids carr,,o•:er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes /no Comments: (note condition of pump hamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Three Ponds Dr Centerville Owner: A. Matthews Date of Inspection: /6—G—fit SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: _/o © cl v l To �� •°C'e &W P/Z';C s J d 1 leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (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 groundwate inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, si fis of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site pJdition Materials of conDimensions: Depth of solids: Comments: (notl, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Yy i o Ll� DEPTH TO GROUNDWATER Depth to groundwater: l S� feet method of determination or approximation: ?° `l �7-&5 7- /�e 1'S !9 F/ (revised 8/15/95) 9 a ,i,/ -0 SUBJECT TO APprO'VAL OF F� B No............... 14B ..... I#RVF-' CON ;IVA-TIOX ........ THE COMMONWEALT4- _A( W1 TT _ N BOARD 0 T EALH ............ ..................0 F.............. ..164.1 .....11----—----------------------------------- . Appliration for Bi_qposal Marks Toustrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: DY-1 U L �07-.ys..........-1......................................... ............................................ Location-Address or Lot N6. _Zk ................................. .........X.A.F10AIC .. A..:.......................................... —Ow Address ......... .....0.0F 41114...V1 .............................. ............................................. . ................................................................. Installer Address Type of Building Size Lot__Z47e,3.Z--------Sq. feet Dwelling—No. of Bedrooms._._..,...... .............. U �_____________________________Expansion Attic Garbage Grinder 44 Other—Type of Building No. of persons...........If.............. Showers (C,,) — Cafeteria 04 1� Other fixtures -----------------------------------------------...................................................................................................... -Design Flow................... 55 ...._._........gallons per person pFr day. Total daily �pw........3Z0.........................gallons. 9 Septic Tank W ..—Liquid capacity] ..gallons Length__49.��__ Width---- n-en=... Diameter_ .... Depth e::-6 Disposal Trench—No. ......... Width V............ Total Length.............7..... Total,leaching area....................Sq. ft. Seepage Pit, No.........I.......... Diameter......16 Depth below inlet......4......... Total leaching area...Z./—.<6..sq. ft. Z Other Distribution box (V� Dosing tank ( ) 0­4 Percolation Test Results Performed by_gi'_'&... "E'SAY... Date...��13A!o �4 r-------------*- .................. Test Pit No. I Az-----minutes per inch Depth of Test Pit------1.4........ Depth to ground water_./`�4 ....... Li, Test Pit No. 2.�4_2 minutes per inch Depth of Test Pit.....17—--------- Depth to ground water.....4''(............... P4 ....j-----Z:� 'J�gso O. Description of Soil....�Z7- U... �4 --t Lain. ---------------------------------------------------------------------------------------------------------------------------------- U ..................................... .....'Z ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------I---------------------------------------------------............................ U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------.............. ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of-.TTLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i jed by the boar of health. Signe . ............ ..... /............... ................................ Date .... ..... Application Approved By-------- ................. .. ......!;�....................... 7------------ ---------- Date Application Disapproved for the following reasons:................................................................................................. ............... ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date .0i.14� X 4"T THE COMMONYVEALTfi OF MASSACHUSETTS . BOARD OF EALTH �.OF............•... t -_ --- - } JNV�t#adiou for Dtipugttl Works Tonutrnrtiun ramd t Application is hereby made for a Permit to Construct ( . ) or Repair ( ) awn' Individual Sewage Disposaf, 3� Sys -------•----------------------------------- -------------------------------- •--.. ... tt=ri& dM, or Lot No. . (*mot 4;p f� U .......... ......--•-----•................................•-••--•-•--.........__...._............ '� �/,Si� lrrrJ Address W Installer Address IC'yIJ! "G aV/�C giz tf Type of Building � e Lo _O_____.........._.......Sq. feet Dwelling—No. of Bedroo _Expansionittic ( ) 443rkqg furinder ( ) # -' aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfix t i s ..------^--••-••-------•- -=-----------••••- ---•----•••-•-•--•-•----1-----;- ----------�`3!j*_-_--•-•-• ---•-f W Design Flow.................. __._..._ gallons per persgS�i flay. Totalt�flafil low..___._ -�. ____..__ __<-Olons. Ix:. Septic Tank—Liquid c � W Disposal Trench—10, �pc�,ty__._.__..__.gallons Length................ Width................ Diameter................ Depth................ t F x _______________ Wid _ --------------- Total Length_______ Total leaching area___Z. 0 _._sq. ft. �, '+-- Seepage Pit No------------- ___'. Diameter____________________ Depth below inlet.__................ Total leaching area---,;..............sq. ft. z Other Distribution box ) DosiW� a ( 3�r!!1 /„ ikJ, Y 4 (a U aPercolation Test_Res alt Performed bY............................................1 ------•----••---------- Date.................I— •------- Test Pit No" 1 _ ....•_minutes per inch Depth of Test Pit.... _'-------- Depth to ground water _ ________________ <s., r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t ;-----••----•--•..........................................•-•......................................................... Description of Shcl____ _ __�,_f_._- ___ ___ �ram.._ { -------------------------------------------------•-----------------------------------------------•---------------............................... W U Nature of Repairs of Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITT LE,• p S 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........ _..... •••---• -••--- ---- _ D ' Date Application Approved BY i .�. ------------- y'Dat '-4 , Application DisapproveN for the following reasons------------------------ -•••------•----••-••--•-----------••-•------••--••-•-•-•---------••••--••••-••-...__._ 3 Date PermitNo..................... -- ------------------ Issued-------•---•---------------------•-------=-------------- `-t Date q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF............... ............ �rrfifirttr oaf f�untp War THIS IS T CERTIFY, That the.Individual Sewage Disposal System constructed ( or R aired ( �) b _.. - -----''------•-------••-2--- --- •------ _ Y • -- ------ r ' "" ' Installer at �- ....� .. »,.•• " - has been ins"Eal el'd in accordance with the provisions ns of T j of Jhe tate Sanitary ode as described i the application for Disposal Works Construction Permit iV' __.. __.___. dated__. ___-2.__�_"_- TIME ISSUANCE OF THIllt,CERTIFICATE SHA NOT BE CONSTRUED AS A GUARANTEE THAT TIME :4 SYSTEM WILL FUP)CTION SATISFACTORY. ----------------^-----_.._. Insector_DATE =..:.:... ..... - i, N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH OF................ . ....... .... ............................. 4.' O. .._�Ef/..�ij.... FEE. ' ._ .......... / Disposal Work T.ttnitr uanOrrinit Permission Is hereby granted -- = = to Construct (�r Repa ( )-an n'i;ju Sewage Dispos Syst J atNo. -•--•• • -•••------- V �( • �G' ` V Street as shown on the application for Dispos Works Construction Permit—No _:__4B.ar Dated___' ____ L ` Hea - DATE---------- �----------•---•--•--•••--••----•--•--_.... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS rj ` ,. x*� • sr -�- e /YOW -GL T --�,u: f,�^Y -.t � �:y�, � . �`s0'FT. v%'9//t/ P� j �� �,• _.� - ✓F� E/ NER 7.�,�E;SEP.T MORE=. Tk� '`✓-:/2""BELOW. F l/Jl°o/N• K s r :. !ikR OE,. 24'!3/AM E:TER COI�/CRF.-f. -COVER ', SNALG 'BE 9RD 7 _TQ _6 AoE . A/✓ EXTRA .P/PE.. R CC/YeRCTE x /y/N. .o/TCN h'EAYy CAST /RON COIiEP .SHALL 13E USED ,CO'YERS� /IV /JR/VEZt/A Y t 0. fi• 2 v M/N� _CO/VCR,- CCU✓ER CL EA IV ry - _. - BACIKF.. L/QU/D LEVEL 4" CAST ` r-',', R.i1.r 2 LAYER IRON P/PE MIN:P/TCN GAL. ° o I • • • . • • • 1 1 p oAo "Rem -T. SEPT/C TANK D/ST, " c n • • • • • • • r• a , q _ WASHED --=-: - j BOX' v • 1 $ • • • • • r .eo • j o .'� _• s a Qp o 1 r •`cFFECT/VE. r` . � o b 3�4��- � �2�� o ° r 1 • DEPTN • • 1 ' • o o WASHE0 STONE t.:•.W-. •r..:.: .. o r • • s • • . • Hop �... a r - 0 1 1 II • • • • 1 1 1 � p o a v� r • • . e • • • . r p ° p PRECAS T SL�•EPAG E /N R'T ELEVAT/ONS ° ► �p t r r ■ •', • • • • r r , o 01 P/7 DR EQUI V, INYERT AT BU/LD/NG _SFo /�T 6 DIAM. /NLET SEPT/C TA,,VK i=T i_ __�L2 FT• U/AMl• C(SEE TRIBULATION, 0U7LET SEPT/C TANK �� -3 CFr C /NLET D/STI4/43UT/ON BOX �•u f T. SECT/O/V OF ` GRDuNO I�IfITET TABLE O UTLET D/STRIBUT/UN BOX F1T. ' /NLET LEACH/N!i f?/T �, r F'r SEN/AGE O/SPOSAL SY3'TEM L EAC"IlvCr P/7 TABULATlD/V SCALE 0.. DmIENS/DN A .3 FT. DES/GN .CH/TER/A 4 - D1AIkNS/aN $—�-- FT. � IVVAfdER OF BEDROOMS D/HENS/ON C—�FT. GARBAGED/SPOSAL UN/7' 1 SO/L LOG TOTAL e57b"ATED FLOH/ 3 3 y GA,i../DAy �SO/L TESTc� #/ SOIL TE57-*2 SD/L TEST NUMBER OF c:EACNIN6i PITS J f^ELE✓. / O f`�ELEY,_ -s O ,DATE OF SO/L TEST G 13 �0 S/OE l. -4CH/NG .49: P/T SQ: FT. U .y I� Z RESULTS JAV17 SSED BY T�-R y�/K/S BOTTOM LC 4CHIN& PER P/T_�� SQ.' FT ._O i4/�. kGk. L p� /y � f'tRCOLAT/ON,RRTE,* L�s� MIAIIINCH TOTAL LEACH//YG AREA •2 C5 C-' SQ.I FT. S-U l3 o t L. 5-ul3 So/L_. PERCOLA7-/ON RATE f�2 T.�..�r✓ M/N.1/NCH RESERI .EL64CN1/VG AREA 2 f�S4.1 FT. w - L� N �c Z, 07- ¢S 7;4,tce PO .!)R 7PR yvE C1 F r s �o Ft03F�T \ GO R S f C-C �� ✓f LI-•,� t t;�a,- *. o .,;XBUNIKIS_. - No.2zlsz"o :. _. �r ELOI�?EDGE E/VCt%JN�'Rf/VG CO, NG' b . ' Gists'EQ` `v ,c. .vt) L7, • <.� r" '112 MA. N ST 3 33 SIB.MAN ST 'SRS• b E. N/3 :MASS SO.. YrtOt/ l;l�IABsf,. ,.. K 6 A,T�R°AAICOCI V''-.' .LLCM v ' ,y,�. .' >,... 3. YNAl. .r. 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L, e T- �s� 1 LOCAT10 SEWAGE PERMIT VILLAGE INSTALLER'S NAME i ADDRESS 4 d U I L D E R OR OWNER A/ 6 y' DATE PERMIT ISSUED- � DATE COMPLIANCE ISSUED Gl- A T 30 �o N _ fJ- lZ MAC /9� Lrx7' Ae4 / t� � �) i i r N all- i K i lk . .......... tf 1�`1%�•i 1 / X /` ��,'!} /�'e � �,`, „wee �A fa/ S 7.,Z_ Al 0 1 �.«..P 1. � P' .e 1 .. t • � r_, a ,f c' t'"'_ .0 r 1.C.,_ /q W i l A f c. ,.M, Ak `i