HomeMy WebLinkAbout0083 THREE PONDS DRIVE - Health 83 THREE PONDS DR., CENTERVILLE
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_C Commonwealth of Massachusetts
Title 5 Official r Inspection Form n _ .
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t.
83 Three Ponds Drive
Property Address Y,
Riley
Y
Owner Owner's Name a`
information is '
Centerville MA 02632 05/15/2019
required for every
page. City/Town State Zip Code Date of Inspection I`:._�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information ¢4 I3 00f;
filling out forms S�
on the computer,
use only the tab A.Riker
key to move your Name of Inspector
cursor-do not Riker Land Construction
use the return Company Name
key.
Box 726
Co
Company Address
South Yarmouth MA 02664
City/Town State Zip Code
508-776-6460 S 14590
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
05/15/2019
Inspk#w0g1ignature 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 Y6
c Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
_ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
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:
® 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:
On inspection of the system the distribution box was found to be cracked and was replaced with
Town permit#2019-173. The septic tank and leach pit were found to be in operating condition with no
failures observed.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I N Commonwealth of Massachusetts
r Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
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 ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp,doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
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:
t
"*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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
❑ ® Required pumping more than 4 times in the last year NOTdue 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 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town 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?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.R26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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 GPD
Description:
Number of current residents: 5
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? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2017=176GPD
2018=154GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
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:
homeowner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp_doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Lam;
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
08/10/1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 5
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.):
No indications of failures or past back ups observed in interior plumbing
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�r
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon concrete septic tank
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5x5x9
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
36"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was observed to be 5'deep with riser on outlet .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,t;
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
!P I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
z � 83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. CitylTown 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
equal to single outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
New distribution box installed with riser inspected by Town Permiot# 19--173 Repairs were made at
time opf inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. CityJTown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain,why:
Type:
® leaching pits number: 1 @6'x6'w/2'
stone
❑ 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
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.1 83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was observed to have stain line 2/3 of the pit with standing water less thewn 1/2 .Reserve
capacity with 2'stone was greater then 1/2 days flow of 165 gallons
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-, 83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lilt
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
` Owner Owner's Name
information is Centerville MA 02632 05/15/2019
required for every
page. City/Town 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
JA 1
3 =, g
39
- S
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
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >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:
08/10/1995
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
USGS did not indicated water with in 15'
You must describe how you established the high ground water elevation:
Hand augur to 12'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Three Ponds Drive
Property Address
Riley
Owner Owner's Name
information is required for every Centerville MA 02632 05/15/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. � ( _ ` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpliLation for BispD8al 6pstem Construction Permit
Application for a Permit to Construct( ) Repa}�Upgrade( ) Abandon( ) El Complete System ividual Components
Location Address or Lot No. Q� �Ce P4�n��/�1S �r'yyuC Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel —? d� A�4(t Ak,,,, P,k 83 7'i fe< P&JS /g jw
Installer's Name,Address,and Tel.No.PD 60,k 7j.{p Designer's N ,Address,and Tel.No.
S'y.,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3?10 gpd Design flow provided PjU gpd
Plan Date Number of sheets Revision Date
Title
c
Size of Septic Tank Type of S.A.S. Q ,tn
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) r )ti! ,` X ' r
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 Health.
Signed Date /15 ja C 1
Application Approved by ' Date
Application Disapproved by Date
for the following reasons
Permit NO. Issued ��
a g I
•1, i
75
No. Fee
y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
_PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpprication for Misposai *pstrm Construction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System dividual Components ✓r
Location Address or Lot No. a3 ,,t p6,,e/s pi A/C, Owner's Name,Address,andQTel.Not.
Assessor's Map/Parcel 1173 66 Xr _0A 1'r(-, S ct Aht" F''k k4 83 -rAK 7f< /" js 1/r r`lK
Installer's Name,Address,and Tel.No.ID Bak 140 Designer's Nam4Address,and Tel.No.
1' Kcr 1 Q..d('o�S�r� S yam+ ,h,, /1►�4 OX& /ti JA
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) U gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
c
Size of Septic Tank Type of S.A.S. rc fJS
Description of Soil
j r /
Nature of Repairs or Alterations(Answer when applicable) ��./f��j/ C��,'�T1H, �o X ,�n ,-or "'n
Date last inspected:
r -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 Health.
Signed Date Jae I
Application Approved by �^r Date S 'l
Application Disapproved by �,i Date
for the following reasons
Permit No. 2 0�q Date Issued �^ 1
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaire Upgraded( )
Abandoned( )by ;��ti- L G �G�i S�.t J'► "" 11
at. '� -� �7u�� j has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.� 13 3dated-
Installer
P p y Fl' '
Designer /11
#bedrooms Approved design flow gpd
The issuance of this ermit hall not be construed as a guarantee that the system will fu is t designed.
Date Inspector
-------------n---------}------------------------------------------------------------------------------------------------------------------
No. l ' Fee
1 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposai 6. stem Construction Vermit
Permission is hereby granted to Construct( ) +! ) Upgrade( ) Abandon( )
System located at 83 n fn Ponas DAK_
and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 this permits 8
5 _ 3_ q 1r 6C�Date I Approved b 0
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PP Y �
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� Commonwealth of Massachusetts
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Subsurface Sewage Disposal System Fonn ' Not,for Voluntary Assessments
83Throe Ponds Dr. Centerville. MA
Property Address
Federal Home Loan &4o� C
Owner --�— —
---
mm,mauon|s
required for Centerville.
_�_______� �� 02632 2'22'12
every page. City/Town 34ate z|pCoun Date ofInspection
Inspection results must be submitted on thisforno. inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form,
�
�
Important: �� ���������U8�������'��n
vvxennmngm� A. General Information
~«
forms on the
computer, use 1 |nspeoto } ^~~
on|ytnetauxey r
. m move your Darrell Stone
cursor do not
usethenxum '`~^'~~ ^'-~c"'
key. Cape Cod Septic
Company Name
PO Box 146S
Company Address
Harwich MA 02045
State Zip Code
508'240'2500 S14995
Telephone Number License Number---
B. Certification
�
| | certify that | have personally inspected the sewage disposal system at this address and that the �
� information reported below is true, te and complete as of the time of the inspection.was performed based on my training and eXperience in the proper function aFd ' aintena.�me of a! site
" sewage disposal ayete | am a DE9 approved system inspector
Title --
Z Passes IL I-- Conditionally Passes
2-26-12
' '-_- 4FrtherEvaluato
.~~
' The system inspector shall oubm;'a. copy of this inspection report to the Approving Authority (Board
. of Health or DEP)within 30 days ofcomp!edng this inspection. If the system is o 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 oftheDERTheorigina| shou|dbeaenttotheoystemmwner
and copies sent to the buyer, if applicable, and the approving authority.
^^^°Thia 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'11x0 ���'Off. f 01�=ins czlon .�*��" x�"�o="�v�°=-p�e`w`,
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Commonwealth of Massachusetts
auk ? Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville; MA
Property Address
Federal Home Loan Mortgage Corp_ _
Owner Owner's Name
information is required for Centerville, MA 02632 2-22-12
_
every page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
Inspection Summary. Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass' section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health; will pass.
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.
El Y ❑ N ❑ ND (Explain below):
t5ins•11/10 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
�5c
83 Three Ponds Dr. Centerville, MA _
Property Address
Federal Home Loan Mortgage Corp. _
Owner Owner's Name
information is
required for Centerville, MA 02632 2-22-12
every page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
B) System Conditionally Passes (coat-):
❑ 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):
A ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Rewired 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 05ici2l Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, MA__
Property Address
Federal Home Loan Mortgage Corp.
Owner Owner's Name
information is required for Centerville, MA 02632 2-22-12
_
every 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
❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day 1ow
t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
I"! Subsurface Sewage Disposal System Form _ Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage Corp. _
Owner Owner's Name
information is required for Centerville, MA 02632 2-22-12
—.
every page. City/Town State Zip Code Date of Inspection
B. Certification (coot.)
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.
❑ 0 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 CiV1R 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 -fle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
■
; Tale 5 Official l s e UForm
� l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage Corp.
Owner Owner's Name
information is required for Centerville, MA 02632 2-22-12
_
every 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?
NI ❑ 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?
❑ IZ 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): n/a Number of bedrooms (actual): 3 -
DESIGN flow based on 310 CMR 15.203 (for. example: 110 gpd x#of bedrooms): 330
t5ins•11110 ':iNe E Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Ailassachusetts
=-
~�~~��N�� �� �"���'~�w~��0 �����������.�~���� ����U�01y�
: Title�N*= �� Official B��0��N Inspection�0 Form
��mmuw
Subsurface 8evva0n Diapmnai Syetemm Form - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, yW/\
Property Address
Federal H Loan Mortgage Corp.
Owner Owner's Name information is
im
required for Centerville, MA 02832 2'22'12
every page. City/Town State Zip Code Date ofInspection
D. System Information
Description:
38odroom reaidentio| dweUin
_ ---_-_---__-_--_'---____-_-__-_
|
.�
�
Number of current reaid Oents� -----------
Does residence have a garbage grinder? Yes NV
Is laundry on a separate sewage system? (if yes separate inspection required] E7 Yes No
| Laundry system inspected? 0 Yea Z No
Seaaona| uae? ' El Yes M No
� Water meter readings, if available (last 2 years usage (gpd)): 15068OPD
Detail:
2011 35.000 ga|kmo
2010 75,000 p1lons
Sump pump? El Yes Z No
Last date of occupancy: 11-2011om
|
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CW1R 15.203): Gallons per day(gpd)
Basis of design flow(oeats/paraons/sq.ft, etc.):
| Grease trap El Yes E] No
`
Industrial waste holding tank present? El Yes E] No
Non-sanitary waste discharged to the Title 5system? El Yea F� No
Water meter readings, if available:
t5i" -nno Title,Official inspection Form:Subsurface Sewage Disposal System'Page rmn
i
Commonwealth of Massachusetts
—,� Title 5 Official Inspection Form
�-!"l Subsurface Sewage Disposal Systems corm? - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan �Ilgtgage Corp__
Owner Owner's Name
information is
required for Centerville, _ Pr,^-, 02632 2-22-12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.;
Last date of occupancy/use: Date
Other(describe below):
General information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) /if yes; attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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 Titie 5 Official Inspection Form'.Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
;,
Title 5 Official 'Inspection Form
i=� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage Corp. _
Owner Owner's Name
information is Centerville, MA 02632 2-22-12
required for _._.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cent.)
Approximate age of all components, date installed (if known) and source of information:
1978 Tank and D-box, 1994 Pit
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 51" _
feet
Material of construction:
❑ cast iron N 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting; evidence of leakage, etc.):
Apparent good condition
Septic Tank (locate on site plan):
45" _
Depth below grade. 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
1000 gallon
Dimensions:
8"
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal system•Page 9 of 17
Commonwealth of Massachusetts
alb;/ Title 5 Official Inspection Form
s! Subsurface Sewage Disposal System- Fora - Not for Voluntary Assessments
Z,nJ
83 Three Ponds Dr. Centerville, MA _
Property Address
Federal Home Loan Mortgage Corp.
Owner Owner's Name
information is
required for Centerville, MA__ 02632 2-22-12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cent.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24"
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle 5 --
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity;
liquid levels as related to outlet invert evidence of leakage, etc.):
Grade to inlet cover 45" Outlet 7" Normal liquid level No sign of leakage
SCH 40 outlet tee
Recommended next maintenance pumping within 1.5 yrs
Recommended maintenance pumping every 2-3 years _
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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection F®r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
:1 W,
c = =Sri
83 Three Ponds Dr. Centerville.--MA
Property Address
Federal Home Loan Mortgage Corp_
Owner Owner's Name
information is Centerville, MA 02632 2-22-12
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related tc 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 ❑ meta! ❑ 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
•11/i0 Tae 5 official Inspection Form:Subsurface Sewage Dispose!System•Page 11 of
?sins 1-
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Commonwealth of Massachus-etts
~�~~��0 �� Official
� 0 ^�~ Form
�
Title 0��N�� ���������� ����� ��NrN��
� �� �� �w�� � ��� � �� ��� �~
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Subsurface Sewage Disposal System Form Not for,Voluntary Assessments
83 Three PondoDr. CentervU�]NA
-' Property
���--------------'-----------'
FederalH L yW Corp.OwnerOwner's
� � � �-��— -----------
mwnerowame
information is
required for Centerville, MA 02632 2'22'12
9
evepage, Q��»wn 5t�p Zip7Code-- Date of Inspection
-
D. System Information (cont.)
DisthbubonBox (ifpresentmuotbeopened) (|ncateonsitap|an).
Depth of liquid level above outlet invert O''
Comments (note ifbox is level and distribution to outlets equal, any evidence of solids carryovor, any
evidence of leakage into or out ofbox, etc.):
Grade to box 20" OK condition 1 Outlet Normal liquid level No sign of leakage
Some scum carryover(removed) No siqn of failure
|
` Pump Chamber(locate on site plan):
� .
Pumps in working order El Yee 7 No
/Uanno in working order El Yea 7 No
Comments (note condition bf pump chamber, condition of pumps and appurtenancaa. etc.):
�
. ^ �
�
~ Soil excavation, . ' . �
If SAS not loca0sd, explain why:
`
^
^
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Commonwealth of Massachusetts
Title 5 OfficialInspeCk.-tion Form
`ri Subsurface Sewage Disposal Systern. Form - Not for Voluntary Assessments
�r 83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home_Loan Mort_g_a__ge Corp. _
Owner Owner's Name
information is required for Centerville, _MA 02632 _ 2-22-12
_.
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Grade to pit 42" Cover 16" Bottom 114" Ponding 3" Some scum
No sign of hydraulic failure
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• 1/10 T,le 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
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage
Owner Owner's Name
information is
required for Centerville, 02632 2-22-12
every 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 poncling, condition of vegetation,
etc.)*
t5ins-11/10 Title 5 Offici2i Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
I
Commonwealth of Massachusetts
;& Title 5
_ fficial Inspection Form
N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Dr. Centerville, NIA_
Property Address
Federal Home Loan Mortgage Corp.
Owner Owner's Name
information is
required for Centerville, _ MA, 02632 2-22-12
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
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t5ins•11110 Titla 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
l i Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!�J
83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage C_orp_
Owner Owner's Name
information is
required for Centerville, MA 02632 2-22-12
_.._
every 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: >4fee+
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: pate
® 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:
Test hole results frorn previous ins"ection 12-8-2010
Bottom of SAS ELV. 92.'
Bottom of test hole ELV. 12.2 NWE
Adjustment 2.6' SDVV-252 Zone C 47.2'
USGS maps indicate GW at 31.6' below grade
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 Fora - Not for Voluntary Assessments
' 83 Three Ponds Dr. Centerville, MA
Property Address
Federal Home Loan Mortgage Corp.
Owner Owner's Name
information is required for Centerville, MA 02632 2-22-12
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, 3, 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•11110 Title 5 O5lcial inspection Form:Subsurface Se%.%,age Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form n s
� Q
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v
lug 83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is
required for every Centerville MA 02632 December 8, 2010
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Septic Inspections
r� Company Name I
19 Hummel Drive
Company Address
South Dennis MA 02660
Cltyrrown State Zip Code
1508)385-1300 S1682
Telephone Number License Number
B. Certification
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 s
❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority ^'
� t
December 8, 2010 z
Inspector's Signattfre 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.
tsi 5•
n 09/08 Title 5 Official Inspection Form:Subsurface Sewage Dlsp sal System Page of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
•" 83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is
required for every Centerville MA 02632 December 8, 2010
page. 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:
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:
i
System meets minimum standards set by Massachusetts DEP at the time of inspection only. This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or
components, or the future structural integrity of system components and represents conditions found
on the day of inspection only.
B) System Conditionally Passes:
El 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):
N/A
t
k
t5ins•09/08 Title 5 Official Inspection Form'Subsurface Sewe a pisposal Systenj rage 2 f 7 ��r-
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8, 2010
page. City/Town 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):
N/A
❑ 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):
N/A
I
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.
I. 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 a
t5ins•09108 Title 5 Official Inspecfion Form:Subsudace Sewage Disposal System•Page 3 of 17
• i
Commonwealth of Massachusetts
Title 5 Official Inspection Form t
Y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 83 Three Ponds Drive, Centerville
Property Address
Terri Meade '
Owner Owner's Name I
information is
required for every Centerville MA 02632 December 8, 2010
page. Cityrrown State Zip Code Date of Inspection
r
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: }
- i
❑ 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 of a public water
supply.
I
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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:
N/A
D) System Failure Criteria Applicable to All Systems:
I
You must indicate "Yes"or"No"to each of the following for all inspections: I
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded ? i
or clogged SAS or cesspool r
Liquid depth in cesspool is less than 6 below invert or available volume is less
❑ ® than day flow
t5ins•09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System.Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M r 83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8, 2010
page. Cityrrown 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: N/A.
❑ ® 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. IT
system passes if the well water analysis, performed at'a DEP certified i.'.
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppri
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.
a ® The system fails. 1 have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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 2.00 feet of a tributary to a surface drinking water supply.
El El
the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone ll 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•09108 Title 5 Official Inspection Form:Subsurface.Sewage t)isposal System!Page 5 of'17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8 2010.
`"'
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)
N ❑ 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?
® ElWas 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 gpd
t5lns-09/08 TIQe 5 Offidal inspection Form:Subsurface sewage Disposal system•rage a of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is
required for every Centerville MA 02632 December 8, 2010
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
1
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? Z Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 dars usa e d 09=68,000 gals.
g ( y 9 (9P )) 08=83,000 gals.
Detail:
Sump pump? ❑ Yes 0 No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ yes ❑ ;-.No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes [
Water meter readings, if available: N/Ar `
_ TO ;Al"1�X
t5lns-09108 We 5 Official Ins on Form Subsurface Sewaipe�Dis'
iI t ,�
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments
µ 83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8, 2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
1
General Information
Pumping Records:
Source of information: No pumping info was available.
Was system pumped as.part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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):
i=
r. f !
t51na'��� 71t1e 5 Official Inapecyon Form;Subsurface Saw�ge Plsposal 8 stem Pe 7 5�,`_
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8 2010
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:
Tank and d-box are original to home. Leaching was installed on 4/28/94 per compliance.
Were sewage odors detected when arriving at the site?' ❑ .Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 6,'+ -
I feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet,
Comments (on condition of joints, venting, evidence of leakage, etc.):
Flushed lines and found clear at the time of inspection.
J.
Septic ti (locate.on c Tank loc on site pla
n):
p )
Depth below grade: 5.5'with riser to 6
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5' X 9' X 6' 1000_ gallon
F
4
Sludge depth: .T
-
'" ,t s
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;�'aqe 8 0( 7 >
ir
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is Centerville MA 02632 December 8 2010
required for every ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) F
Septic Tank (cont:)
Distance from top of sludge to bottom of outlet tee or baffle 2, 8"
1 �
Scum thickness
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
1311
I
How were dimensions determined? Probe/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.):
Pvc inlet and outlet tees were present. No evidence of leakage or damage.was found at the time of
inspection.
i
Grease Trap(locate on site plan):
Depth below grade: N/A ;
feet
Material of construction:
❑ concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions:
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle NIA
Distance from bottom of scum to bottom of outlet tee or baffle N/A s
Date of last pumping: N/A
Date
i
t5ins 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of.17 I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
83 Three Ponds Drive, Centerville ,
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8 2010
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.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
f N/A
Date of last pumping: gate
Comments (condition of alarm and float switches, etc.):
N/A
x Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page t 1 o(17 i '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•�'r 83 Three Ponds Drive, Centerville
Property Address
Terri Meade _
Owner Owner's Name
information is Centerville MA 02632 December 8 2010
required for every ,
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 level with
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.):
D-box was found in working order.
l
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.):
N/A 4
Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
N/A
'i
j
i
l
t5ins•09108 Title 5 Official Inspechon Form:Subsurface Sewage Disposal System+Pape 12 of 17
Commonwealth of Massachusetts
Asm. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8, 2010.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 -5.5'X6'with 2'of stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches I number, length:
❑ leaching fields number, dimensions:
El 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.).-
Soil was sandy. Leach pit was found with 4' of water present with a visible stain line approx. 1' below
inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of
inspection.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑;Yes
❑
l5ins•08/08 We 5 Official Inspection Form Subau ce SeW a a S t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is Centerville MA 02632 December 8 2010
required for every ,
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.):
N/A
I
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A.
Depth of solids N/A
Comments (note condition of sojy-signs of hydraulic failure, level of ponding, condition of vegetation,
etc):
N/A
i
i
t5ins•09/08 Tide 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
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8, 2010
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
9 p Y 9 .
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
w�t _ .13
3 0 0
_ o
t
3 3� ,
ri -1Z yb _
II
t5ins•09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System+Page 1000 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is
required for every Centerville MA 02632 December 8, 2010
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: pate
® 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:
SDW 252 Zone C 47.2' 2.6' adjustment
You must describe how you established the high ground water elevation:
Hand augered 3.0' below bottom of leaching with no water found at a depth of 12.2'. Groundwater
adjustment at the time of inspection was 2.6'. Bottom of leaching at 9.2" was found not to be located
in the high groundwater level at the time of inspection. USGS groundwater map shows groundwater
to be approx.31.6' below grade.
,
Before filing this Inspection Report, please see Report Completeness Checklist orb next gage
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page�6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form .- Not for Voluntary Assessments
83 Three Ponds Drive, Centerville
Property Address
Terri Meade
Owner Owner's Name
information is required for every Centerville MA 02632 December 8 2010
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
=4,
6
t5lns-09/08 We 5 Officlal Inspedon Form:Subsurface Sewage Dlspoo System l f+dge 170117
I ,
BORTOLOTTI CONSTRUCTION, INC.
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address Prop Ikee e S Q
Date of Inspec Map ar O�� Owner e�
PART A — CHECKLIST
CHECK IF THE FOLLOWING HAVE BEEN DONE:
PUMPING 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 RATES DURING THAT PERIOD. LARGE COUJI(ES 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.
HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP.
THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
LL SYSTEM.COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE.
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,
EPTH OF SCUM.
THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR
APPROXIMATED BY NON—INTRUSIVE METHODS.
THE FACILITYOWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER
MAINTENANCE OF SS S.
PART B — SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL
- No of Bedrooms No of Current Residents Garbage Grinder
e.J Laundry Connected to System Seasonal Use
NON RESIDENTIAL:
Calculated flow) '
WATER METER,READINGS;IF AVAILABLE:
GALLONS
Pumping Records;and Sou►ce of Informa'on:
SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS
Reason for Pumping:: "`
TYPE OFsTEM f
✓ Septic,�tank/distribution box/soil absorption system i
SinglerCesspool . Overflow Cesspool Privy
Shared system(rf yes,attach previous inspection records, if any)
Other(explain)
Approximate age ofiaH components Date installed,If known. Source of Information.
SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?
=, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
Depth below grade: /Z // Dimensions: Cx�
�7
Material of construction:. Concrete Metal FAP Other}
Sludge Depth Z w Distance from top of sludge to bott�m of outlet tee or baffle
36
Scum Thickness Distance from Top of Scum top of outlet tee or baffle
Distance from bottom of Scum to bottom of outlet tee or baffle /Y
Comments-
DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT
Comments:: '
PUMP CHAMBER: Pum s in working order?
Comments:
SOIL ABSORPTION SY TEM SAS :
IF NOT PRESENT,EXPLAIN:
TYPE: �
Comments:
CESSPOOLS:,! Number and configuration
Depth-top of liquid to'inletinvert Depth of solids layer Depth of scum layer
Dimension of cesspool Materials of construction
Indicadon,of groundwater Inflow(cesspool must be pumped)
Comments: ;`
PRIVY:
Materials of construction
Dimensions Depth of solids
1'
Comments:
r
yx ' "t
Y
H
o � .
,.. Uf3SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B — SYSTEM INFORMATION (Continued)
SKETCH'OF SEWAGE'DISPOSAL SYSTEM:
INCLUDE TIES`TO AT LEASTaTWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS.
LOCATE ALL WELLS'WITHIN 100'
ll3 Rear
t
* /r
DTO R DEPTH TO GROUNDWATER
METHOD OF:o a O APPROXIMATION;
c Via= w
1 ,.,,. ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�d t1 s r
PART C - FAILURE CRITERIA
' (Idke�Ds Y,ye ND—not dete
s N no Nrmined Describe basis of deterrninatlon.It'�,ot determined',explain why not)
Backup$.,Sewage into Facillty?�
Dls'ha`rrge or pondIng of effluent to the surface of the ground or surface waters?
�( 'Static�liquid level inz the districution box above outlet invert?
":Llquid:' h in cesspool, 6°below invert or available volume, 1/2 day flow?
It/ Regwr, , pumping 4 times or more in the last year? Number of times pumped
Septic tank is-meta cracked structurally unsound?substantial infiltration?substantial exfiltration?
,>-1 gnk-failure Imminent
kdsyN fi�,F 4r �{ 1 ; .•.., -
xrlsxanylportion of the AS,cesspool or privy, below the high groundwater elevation?
Within SOJe+e#of a surface water
` With in., do feet of a surface water supply or tributary to a surface water supply.?
I .
?
;Wd6in;6 Zone I of a"public well?
Wlthin 50 feet of a private water supply well?
Wdhin 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)?
Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
qua lit yanalysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for
;coldorm bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen.
PART D — CERTIFICATION
INSPECTOR: ROBERT J: BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS
COMPANY„ x BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399
x4a a
CERTIFICATION STATEMENT
I CERTIFYTHAT I HAVE PERSONALLY,INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS.AND THAT THE INFORMATION
ACC
REPORTED'lwmUEURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY
RECOMMENDAT.ION:'REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE
IN THE PROPER FUNCTION;AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS.
J,.
CHECK ONE
I HAVE�'NOT,FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC
HEALTH;OR THE'ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS
STATED IN THE°FAILURE CRITERIA'SECTION OF THIS FORM.tK
'I HAVE-DETERMINED THAT.THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN
S10 CMR 16 303 TFiE BASIS FORTHIS DETERMINATION IS PROVIDED IN THE°FAILURE CRITERIA"SECTION OF THIS
:FORM
.r
INSPECTOR'S SIGNATURE
DATE I4
s
ORII:iINALTO SYSTEfNOWNER,COPIES BUYER(If applicable),APPROVING AUTHORITY
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TOWN 6F BARNSTAB/LE
LOCATION � /��� Y�O.S' r, r c�/J SEWAGE lk=2
VltLAGE[�f, ', '. ie�_ ASSESSOP MAP & LOT �3`075
PvJ P S ' ` ��" �
NAME&PHONE NO. (4)1I b�-� o�l�lP���
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS /
BUILDER O OWNER i /`G ��J e
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facilityo/v Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) IV 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 ��jjet'of,.,lea
`chingg ffalcili / Feet
Furnished by,75l/ / Yam/ �/O IZT�C/.0
..
��
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..
4
TO
WN OF BARNSTABLE
?
LOCATION 7Mre SEWAGE #
VILLAGE&,e)kro f f-� ASSESSOR'S MAP & LOT/�QC-�
INSTALLER'S NAME & PHONE NO.Ar klo j4Zi a"P, 7e% -�
SEPTIC TANK CAPACITY //060 Q2/' 7')_-
'LEACHING FACILITY:(type) (size) a( /O
r
NO. OF BEDROOMS PRIVATE WELL R PUBLIC W�TER��
BUILDER R OWNED � /r __.�
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
3�-�. __,
ea
3�' �
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ay' ys'
..............................
APPRCWW THE COMMONWEALTH OF MASSACHUSETTS
rn le Corm Dope nt BO A R D OF HEALTH
TOWN OF BARNSTABLE
oiq�ed Date
Apli iration far Diin.pasai Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (VC) an Individual Sewage Disposal
System at:
Location-Ad ress or Lot No.
Ow er
a ...... ...U�9 .--- � .. � Address
!/..1r4—f�.1-�... ./�....
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__________________ -
Dwelling Attic ( ) Garbage GrindeL_�- j'
aOther—Type
of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
QOther fixtures -------=------------------------------------------------------------------------------- -----------------------------------------------------------•-
W Design Flow________________-��---------------gallons per person per day. Total daily flow-------------- ..................gallons.
WSeptic Tank—Liquid capacity_rOG'kxalIons Length................ Width---------------- Diameter----.----------- Depth................
Disposal Trench— No. .................... Width.........._- x p �.__..._.. Total Length............. Total leaching area...................sq. ft.
Seepage Pit No--------- Diameter--------- Depth below inlet----&........... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date......................................1.4
..
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-._--_-------__•--_-_--.
a' ............................................................................................................................................................
0 Description of Soil.............................................................................----------•---------------...-----------------------------------------------••-•---•-•---.
x
(,) ----•-••-•--------•-•--•....................•-•--•--............------•---...-----...------..................-•-•---•-•---•--•-••--•--•----••-------.........._....-•------------------•------•-•---....
W
UNature of Repairs or
( 1Alterations— n�s w�e-�r—when applicable(-. --f in� W-�' �r.....r ...- - ' -- 0.- __.$`_..__.
..........
..-. N ! ....
?^J S" r T !3L ✓1!1 -1 �-6¢L,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s b n issued b he rd of health.
�,/ 4
Signed ---------- -- -----------(-�i✓(.---- ---- -----.,....................... ........... ............
Application Approved By ......... ,,�,��+ ..�...'�`'`"`" ` Due
Application Disapproved for the following reasons: ............................................................................. ......... ............
------ -------------------------------------------------------- ---_---------------------------------------
4 Dace
Permit No. im• Issued
------------------------------------------------------ ' .....
Dace
..... ................
......
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
7/TOWN OF BARNSTABLE
Appliratiou for Dhnpw3al Works Towitrurtion Vamit'
Application is hereby made for a Permit to Construct or lCepair an Individual Sewage Disposal
System at:
.....
�7
2.0.......7 , 6/^JCS..................I.......................................................... .✓.........................................................
Location-Address -7 or L000,, _7�
77- ..................... .............................a�.�j..........e1j.0.............------ ...................... .........................................................
Owner S_ Address
..... .............. C- t............ .......................6,................. .... l . .................k' 1 .s.............................
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder,.-(--')`'/W
a
Other—Type of Building ---------------------------- No. of persons__________---___--_------. Showers Cafeteria
1 Other fixtures .... ----------------------------------------------------------------------------------------------------------------................................
Design Flow________________ -----------------gallons per person per day. Total'daily flow-------------��-----------0
--------------------gallons.
1:4 Septic Tank—Liquid capacity_ Q-4k.gallons Length________________ Width----_._-----___. Diameter_-_-.------_-_- Depth........__......
Disposal Trench—No. .................... Width..........I,--------- Total Length_.__..._.__........ Total leaching area....................sq. f t.
Seepage Pit No-------/.......... Diameter--.-.--./A---- Depth below inlet....&<.............. Total leaching area..................sq. ft.
ZOther Distribution box Dosing tank
Percolation Test Results Performed by-----------------------------------------------------------1�...... ------ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit__..-.-_---__e------ Depth to ground water-_-._.----.---_____--...
GT., Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
P4 .............................................................................................................................................................
0 Description of Soil.......................................................................................................................................................................
...............................................
----------------------------------------**--------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------W----------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._-.-_:2L-rouc!�__-r--------U,5.4 ......j
<n_4 64_4, r2/,-7— _j -;t /9 L46�
L.............................................................. ... ................................................. ..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation.until a Certificate of ComplianceKlis be n issued by the board of health.
p / ,
Signed ..........
..........//'
........... ------------- --------------' Date-------------
Application Approved By ...........2. ---Nb ---------------- --
Application Disapproved for the following reasons.: ----------------------------------------------------------------------------------------------------------------- --------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------
Permit No- -------- ------ --—------------ Issued ..........................................................Da te
----------o
D
——— ————————————---—Z---—————— —————————————------——
———————————————- -—————
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate of Contplianre
THIS IS TO CERTIFY-That the Individual Sewage Disposal System constructed or Repaired
by -------------------------------- ------------f5�--------------------------------------------------------------------- ---- ---- ------------------------------------------------------------------------------- -
'Install"
—7Z/
at ----------------------------------------------------
------ IC6 . (_-, ✓/ttC
-----------------------------------------------------------------------------------------------------
---------------------
------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental 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 SATtS_FACTORY.
DATE-------- Inspector ---
-- --------- --Z__- ----------_---------------------- ---- ----------: -----------------------
-——--————--—--—------—————---------------——-------------------—----——------THE COMMONWEALTH OF MASSACHUSETTS 0
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE.....
Permission is hereby granted..... 777_/�,L-iU 1-1-7.......&�,/? ... ..................................................................
......................................
to Construct or Repair an Individual Sewage.,Disposal System
at No................................... -7-iL4,ZFF__ ;dl \J&�.........4W.
....................I............................. ........... ... ............
Street
as shown on the application for Disposal Works Construction Permit Nolv---!&Z__ Dated......4/-,---
........................................ .............................................
ard of Health
DATE............. _----------------
7..... ---------7.....
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
L O CATION S,E•W A G E PERMIT NO.
4 :zr - G ��
VILLAGE t
INSTA LLER'S NAME i ADDRESS
� L9 C_ 'e-
B U Il D E R 4 OR ` OWNER
LO
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
T
A �1
3`
. 3
'c if /
70
No.._....61( ------- F>cs. ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
1.G7.es3.tom......................OF........... j�d
Appliration for Dhipwial Works Tonstrnriinn rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
........................... .....7_. .. s fir- - ,� ¢: ...................................
Loca ion-Address l or at
.._......... �c>s �,5..._. .........
G t 1.4 (.... -4 s ...............
1� Owner Address
. ........................... •..............................
Installer Address
U Type of Building Size Lot_._./�___6,�,7.Sq. feet
Dwelling—No. of Bedrooms........`�........................................................ Attic ( ) Garbage Grinder ( )
�............. No. of/ersons-_---_-•_-__�...____-__- Showers — Cafeteria p., Other—Type of Building _____________ p ( ) ( )
A'' Other fixtures ..................................
d •-----------------------
•-------------
-------------
W Design Flow......2.,R.Ca.........................gallons per person per day. Total daily flow_--_---•-------------------
-................gallons.
WSeptic Tank—Liquid capacity............gallons Length..... ........ Width___-_....... Diameter................ Depth................
x Disposal Trench—No. _._./......._..�Width_...__4...._...... Total Length..............•..... Total leaching area....................sq. ft.
Seepage Pit No______________ _____Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Res Its • Performed by.....E1 .C... Ldl�e��. Date
. . /
Test Pit No. lmutes per inch Depth of Test Pit...../iP.!... Depth t6 ground water..)4Ot4�_.S_.2oW
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
s • ......__...11
.. ......
-- 00.
ODescr>ption of Soil / Ie? r� d
.... ----------- ...----
44h �
W --- ---------------------- -------------------------------------------------------------------- ----------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when icable...............................................................................................
---------------------------------•-•-------•-....---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI I''
p 5 of the State Sanitary Code— The undersW
herees not to place the system in
operation until a Certificate of Compliance has been ' su by BaSig d......_._ .. . •--••......•... ................................
Date
Application Approved B ..
Date
Application Disapproved for the following reasons-------------------------------------------------------------•--------------------- .........................
.....---•---•-••••-----•....••-•••---••-••••-•-•••--••••-•-----•-•--•-•••-----•-•.....•----•-•--•--•••••.••••-•-••--•-•--••••••••--••...--•••--••-•------------•......---••----••---•-----•••-•---......
Date
PermitNo.....................................................:... Issued.......................................................
Date
...... FEB ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..................OF.......... ie................................
Appliration for 0hipwial Workii Tomitrurtion Prrutit
Apprication,is herebyr made for a Permit to Construct or Repair an Individual Sewage Disposal
System
5-. 1-e. ...... I... ..........................
................................... (..............
Loction,,Add,ess y 1 4 or Lot rib.
_--_----------------
........... ........... ...................
Owner Address
............ ................................ .................................................................................................
.2
Installer Address
Type of Building Size Lot...Jr e..4/_;'..Sq. feet
Dwelling—No. of Bedrooms...... ...............................Expansion'Attic Garbage Grinder ( )
Other—Type of Building ---------............... No. of persons__._______:__` +--------- Showers Cafeteria ( )
PL4Other fixtures .....................................................................................................................................................
Design Flow_.___.A.A.6.........................gallons per person per day. Total daily flow.............:..............................gallons.
s:4 Septic Tank—Liquid capacity............gallons Length.....A........ Width._..`________ Diameter_____________-F Depth.____.__._.___--
W
Disposal Trench—No. ......./.......... Width_.____ '____________ Total Length____________________ Total leaching area....................sq. ft.
Seepage Pit No-_-----------------------Diameter.................... Depth below inlet___._______________. Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test R�eslts, Performed by...__ 7'4�1 Date....
0. per inch ' Depth of Test Pit.. Depth to ground water-_14!P�44_e
Test Pit N ... -------
Test Pit No. ................minutes per inch Depth of Test Pit__-__.._..__________ Depth to ground water.-____._.._._________.._
............................................. . .............
---------------- ...........if.................. ?'1--0
0 Description of Soil ;.
.................... 4*-
........ . . .... . ............. -------/;q..........._:5..... Y'&
............
U ....................... ...............................................................................................................................................................................
Z.Z. ---------------------------------------------------------------------------------------------- ----------------------------------------------------------......................................
U Nature of Repairs or Alterations—Answeer w�hhe11le-----------------------------------------------------------------------------------------
.................
................................................................ ..............................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE 5 of the State Sanitary Code— The undersigned fu her a ees not to place the system in
'u It;;.
0 '.7
n su by,,,�e... ard, iea 4.
'00 operation until a Certificate of Compliance has been
Ig sru,"O"
..... .................... ............ ............................ ................................
Date
Application Approved. By.._...... .... .....
/*.. ......
Date
Application Disapproved for the following reasons:................................................................................................................
.......................... .............................................................................................................................................................................
Date
PermitNo......................................................... Issued•.......................................................
Date
-,THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................-.OF.........-.- 4.........................
(9rdifiraft of Toutplitturr
THISJS TO CERVFY That the Individual Sewage Disposal System constructed, or Repaired
by......... ....... 4 . ..... ...............I..........................................fo
............................................4--------------------
at...... .................... .. ....... .A_4�---- ...........----------.........V------- ... .......................
has been instilled in accordance with the provisions of TI 7' 5 h State Sanitary Code as described in the
Y
application for Disposal Works Construction Permit No.__. 7----- ►-
__ ......... dated__A.!W!�O.....711f.-f.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C94STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector4._,_.;..:!F!!.................................................................
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... �OF........ ...................
No j-
........ FEE.... Z
....................
..............
Mops 1=or unstrhwi "anat
y ned... ------------- ...... _-____------_---------_-----
..............Permission h
to Construet C or Re Ind' j(dua D age Psal. stem
a, U ...... !t....... ------ .............i..............
Z'a�ee
as shown on the application for Disposal W
orks Construction Permit --- 44 - 71-
_.W47 �. ,�4ted..........................................
.............:7 -----_----...............
Board:of Health
DATE.... ................................I.........................................FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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p NO.22162 Q V'
STEP�,
ANAL ,1
LEGEND
z EX4STING SPOT ELEVATION 0x0 CERTIFIED PLOT ' PLAN
EXISTING .CON:TO,UR — O — — — . L-v T £�` ttI2EE Pa�DS . Dp "b
F114 SHED SPOT , ELEVATION L.0
:.".FINI;S.HE.D_.C.O.N_T_OUR 0 ---- --C iV7-E2 ✓i�LE
s- . IN
APPROVED = BOARD OF HEALTH
a `1;
DATE AGENT! .. - SCALE !/ DATE : `I � 2 k'
•.4.0 7
DI�PEOGE ENGINEERING CO.;�ING�'i
_ CLIENT -L E/,3 E L
I CERTIFY THAT THE PROPOSED
EGISTE0Ed REGISTERED JOB NO.
O D_ Sr- BUILDING SHOWN ON THIS PLAN
* CIVIL II LAND CONFORMS TO THE ZONING LAWS
ENGINE_ER� SURVEYOR DR. BY ! �_ _ OF BARNSTABLE , MASS. . .
33 IN MAIN ST 712 MAIN ST. CH. BY
SO YARMOl1`TH, MASS. HYANNIS, MASS
SHEET-1 OF Z DATE REG. LAND SURVEYOR-
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