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HomeMy WebLinkAbout0018 VALLEY BROOK ROAD - Health 18 VALLEY BROOK RD., CENTERVILLE A = 189 164L34L All/ llll UPC 12634 NO.2-153 OR HA$TI804 YN e t'7 r Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 18 Valley Brook Road Property Address Hilary Greene _..._. Owner _. Owner's Name information is required for every Centerville ✓ Ma 02632 1 1/7/2020 _.� -._..:_ ___..._ —__ _..._ page. CrtyfTown State Zip Code Date of Inspection �� t 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. irringoutf when A Inspector Information cS( ISA33 fill out farms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor'-do not S.M.Jones Title V Septic inspection use the return _ key. Company Name 74 Beldan Lane Company Address Centerville Ma 02632 CltyfTown State Zip Code 774-248-4850 smjonestitle5@gmail:com, SI 4522 lean smonestitle5.com 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 CHAR 15.000);.I 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 wasperformed 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 11n/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health orDEP)within.30 days of completing this inspection. If the system has a design-flow of 101 .,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- PI!ease 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. t5€nsp.dw•:rev.7128f2018 Title 5 Qfnaia!inspection Fenn:Subsurface Sewage Disposal System+Page 1 of 18 Commonwealth'of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 18 Valley Brook Road Property Rddress Hilary Greene Owner owner's Name information is Centerville Ma 02632 1117t2020 required for every ._. ._�_- ___ page. G�ty/Tawn State Zip Code f)ate;of Inspection C. inspection Summary Inspection Summary: Complete 1, 2, 3, or 6 and all of 4 and 6. 1 j System Passes: . ® t 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 notevaluated are indicated below. Comments: The property located at 18 Valley Brook Rd Centerville is served by a.Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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) t5iriap.doc•rev.7t2812018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Aage 2 of 18 CommonrweaM of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 18 Valley Brook Road Property Adds Hilary Greene Owner Owner's Name information is Centerville Ma 02632 111712020 required for every page. Cityfrown ' State Zip Code Date of Inspection C. inspection Summary (cunt.) 2) System Conditionally Passes(cone.): ❑ 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 inthe distribution box.due to broken or obstructed pipes)or due to a broken;,settled or uneven distribution.box, System will. pass inspection if(wiM approval of Board of Health) broken.pipes)are replaced ❑ Y ❑ N ❑ NO(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 times.a year due to broken or obstructed,:pipe(sj.The system will pass inspection if.(With approval of the Board of Health): El broken_pipe(s)are replaced Y ❑ N ❑ ND(Explain below) obstruction is removed ❑ Y" ❑ N ❑ ND(Explaitvbelow): 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 16.303(1)(b)that the'system Is not functioning In a manner which will protect public:health, safety and the environment: t5insp.doc•rev:7t2&IZ019 Title 5 Official lnspectk)n Forth:Subsu face Sewage Disposal system•Page 3 of 18, _ c Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18,Valley Brook Road Property Address Hilary Owner Owner's Name information is Centerville Ma 02632 1117/2020 required for every CitytTawn page State Zip Code Date of Inspection C. Inspection Summary,(cont.) Cesspool or privy is.within 50 feet.of a surface water E 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 $ASand the SAS is within a Zone 1 of,a public water supply, Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. nI The system has aseptic tank and SAS and the SAS is less than 100 feet but 50.feet or more from a private water supply well". Method used to determine distance: This,system passes if the well water analysis, performed at a DEP certified laboratory, for 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 rnust 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 orsystem component due to overloaded or 0 z clogged SAS or cesspool 0 g Discharge or ponding of.effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5imp.doc•rev.7YdSW8 Title 5 Offidal,inspection Form:Subsurface Sewage Disposal System•Page 4 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Valli Brook Road Property AddressOwner Owner's Name information is Centerville Ma 02632 1117/2020 required for every _.._ ---- page Cityrr wvn State Zip Code rate of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cone.) 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 El E than,%day flow Required.pumping more than 4 times in the last year NOTdue. to clogged or obstructed.pipe(s)..Number of tirnes pumped" [ 0 Any portion of the SAS,cesspool or privy is below high ground water elevation. E 0 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. Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Z 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 conform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn 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 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 fads.The system owner should contact the Board of Health to determine what wilt 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 10000 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 C.A. Yes No Q [] 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 wafter supply, , the system is located in a nitrogen sensitive area(interim Wellhead ProtectionEl �n ' 1,11 Area—1WPA)or a mapped Zone ll of a public water supply welF MMpAoc•rev.7MM18 Tole 5'Offidal fnspedjan Form:Subsurface Sewage Disposal system•.Page.5 0:18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments 18 Valley Brook Road Property Address Hilary Greene Owner Owner's Name information is Centerville Ma 02632 11/7/2020 required for every - �...._._. _..�.._: page• . CitytTown State Zip Code Date of inspections 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 C.4 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 1.5.304. 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 aft inspections: Yes No Z E] 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? El available as built plans of the system obtained and examined?(if they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the.site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? Z 0 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 0 ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and locatlon of the Soil,Absoiption.System(SAS)on the site has been determined based on: Z ❑ 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)[314'CMR 15.362(5)] t5imp.dor rev.MCM18 Title 5 Official Inspection Forth:Subsudace Sewage Disposal System Page 8 at 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form-Not for Voluntary Assessments 18 Valley Brook Road Property Address Hilary Greene Owner Owner's Name information is Centerville Ma 02632 1117l2020 required for every _ page. city/Town State Zip Code Date of Inspection D. System Information I. Residential Flow,Conditions: Number of bedrooms(design): 3 -�- Number of bedrooms(actual): -�--- DESIGN flow based on 310 CM.R.15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes [ No Does residence have a water treatment unit? ❑ Yes Z Na. If yes, discharges to' Is laundry on a separate sewage system?(Include laundry system inspection information, n this report.), El,Yes 0; No Laundry system inspected? ❑ Yes No:. Seasonal rise? ❑ Yes Z No Water meter readings, if available(last 2 years usage(gpd)) Detail: Sump pump? ❑ Yes 0 No Last.date of occupancy: Da gcurrent tSirisp.doc•rer.'712612o78 Tide 5 Of rml Inspection form:Subawfaw Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, * 18 Valli Brook Road Property Address - Hilary Greene _- twuner Owner's Name information is Ma 02632 11/7/2020 required for every. Centerville page. cityrrown Stake Zip Code Date gf Inspection D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flog(based.on 310 CMR,15.203): aHons per aay'(gd) 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? n 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: Was system pumped as part of the inspection? ❑ Yes 0 No If yes,volume pumped; gatlans How was quantity pumped determined? Reason.for pumping: Wnsp.doc•rev.7/SMI8 TKto 5 Official Inspection Form,Substdace Sswagp Disposal Systen .Page 8 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Valley Brook Roadm---- Property Address NiN ag reene Owner Owner's Name information is C_enteNille Ma 02632 11/7/2020 required for every _ — — page. Cityfrow n State Zip Code Date of Inspection D. System. Information (cunt.) 4. Type of System: Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool [� Privy El Shared system(yes or no)(if yes,attach previous inspection records,if any) [l 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,l/A system by system operator under contract Tight tank.Attach a co of the DEP approval. 9 PY P Other(describe): Approximate age of all components,.date installed.(if known)and'.source of information:. original system installed 1985 per town records Were,sewage odors detected when arriving at.the site? ❑ Yes Z No 5: Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: F1 cast iron 0 40 PVC [Q other(explain): Distance from private water supply well or suction line: feet Comments(on condition.of joints, venting, evidence of leakage,etc.) Joints in good condition, no leakage,vented through roof.; t5insp.�c•rev:>7t26 A18: Title 5Off-181 lnspedbn Foon:Subrurface Sewage Dispose!system•Pages of,18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-. Not for Voluntary Assessments 11 11 P.Y�) 18'Valley;Brook Road Property Address Hilary Greene' Owner Owner's Name information is Centerville Ma 02632 11/7f2020 required for every --- --- — -- -- C frown. Date of Inspection �Y State Zip Code page.: D.';Sptem Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 0 concrete C] metal ❑fiberglass ❑polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes No Dimensions: 1QQ0�allons Sludge depth: 2"_. ...: Distance from top of sludge to bottom,of outlet tee or baffle 3'5 Off Scum thickness 71' Distance from.top of scum to top of outlet tee or baffle - - — Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? Opened covers and took measurements 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 recently pumped and should.be done again every 2 yearsn-for proper maintenance.Water level was even with outlet invert,tank was structurally sound and not.leaking. t5insp.doc•rev.7f2&MI8 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form. Not for Voluntary Assessments 18 Valley Brook Road Property Address Hilary Greene Owner Owner's Name _. _. __.. information is required for every Centerville Ma 02632 11/7/2020 - --- page. Cityfrown state'T Zip Code Date of Inspection D. System Information (cone. 7. Grease Trap(locate on site plan): Depth below.grade: feet Material of construction: E concrete F1 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):, ' I Dimensions: Capacity; gallons Design Flovir gallons per day t$in�t.�c•rev;TtZ8f2Q18 Titles Official InspeeUon Form:Subswfsce Swwap Disposal syatem•P8P 11 of 18. 1 Commonwealth of Massachusetts Title 5 Official Inspection I=orm Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 18 Valley Brook Road _ Property Address: T — Hilary Greene Owner owner's Name Information is Centerville Ma: 02632 11f7l2020 required for every page, crtyrrown 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 um in : � ----- p P 9 Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required)'.Is copy attached? 0 Yes ❑ No: 9 Distribution Box(if present must be.opened) (locate on site plan): Depth of liquid level above outlet invert oil 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.): Distribution box was video inspected and found level:and-in good condition with no rot.Water level was even with outlet invert with no signs of past.backup. t5Osp tWC•rev:712611018 Titte;5 d clal Inspection Form'subswface;sewage oisposal:system•Pop12 or fe Commonwealth of Massachusetts Title 5 officia Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _6 18 Valley Brook Road PropertyAddress Hilaryene Owner Owner's Name information i e required for every Centerville Ma 02632 11/7/2020 —. page; Cityrrown State Zip Code Date of Inspection D. System Information {cunt.} 16. 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. SoE1 Absorption System(SAS}(locate on site plan,excavation not required}: If SAS not located,explain why: Type: leaching pits number: 1 x 1000 gals leaching chambers number: leaching galleries number: leaching trenches number, length: [] leaching fields number,dimensions: overflow cesspool number: z innovative/altemative,system Type/name of technology: mnsp.doc•ray.7P saois Tice 5:Orricial inspection Form:Subsurface Sewage Disposal system Page 13 or 18 Commonwealth of Massachusetts Title 5 Officia inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 18 Valley.Brook Road Property Address Hilary Greene owner ovuner's Name information is required for every Centerville Ma 02632 11/7/2020 page, CrtyfTown State Zip Cone Late of inspection D. System Information (cunt:) 11. Sail Absorption System(SAS)(coat:) Comments'(note condition.ofsoil, signs of hydraulic failure, levelof.ponding,damp,soil,condition of vegetation, etc.): Leach pit was located and excavated, Pitwas found dry with:a stain line approx T from bottom. Pit wails were clean with no sign of past overloading. 12i Cesspools(cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration — Depth tap of liquid to inlet invert Depth of solids layer Depth,of scum layer Dimensions of cesspool Mater7als of construction _..__ Indication of groundwater inflow n 'Yes El No Comments (note condition of soil, signs of hydraulic failure, levelof ponding, condition of vegetation, ftsp.doc•rev.7r26=18 'r to 5 OffeW Inspection Form,Subsurface Sewage Disposal System.w Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma-Not for Voluntary Assessments .y 18 Valley Brook Road .. _ .. Property Address. Hilary Greene Owner owner's Name _...-� information is required for every Centerville _ Ma 02632 11/7/2020 page. City/Town State Zip Code Date of Inspection D1.1 System Information (coat.) 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,) Mnsp.doc rev.7128 OM, Title 5 Official tnspecthn Fomt:Subsuufaoa Sewage Dispoaat Syatem•pogo 15 of 18 Commonwealth of.Massachusets Title 5 t)ff ciao InSpect an Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Valley Brook Road Property'Address Hilary Greene Owner Owner's Name information is.every required for e Centerville Ma 02632. ._ 11/7/2020 page. Gityffown State Zip Code: Date of inspection j D. System Information (coat.) 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 qZ i 3 8 q 7 6 iY 1 t5insp cbc-rev.72rs1LO18: Tate k idai inspedion Form.subsurface sewawoispasal System.•Page.t6:of.18. Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Valley.Brook.Road Prop"Address Hilary Greene Owner Owner's Name information is required for every Centerville _�_:— Ma 02632 11/712020 page. Clty(Town state Zip Code Date of Inspection _ D. System Information (cunt.) 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 propertyfobservation hole within.150'feet of SAS) Checked with local Board of Health-explain: Checked with.local.excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe'how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps: Before filing this Inspection Report,please see Report Completeness Checklist on next;page. t5irep,poc•rev.7YLWWO Tote 5 Official Inspection Form:Substrface Sewage disposal System•Page 17 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form - y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Valley Brook Road Property Address Hilary Greene Owner owner's Name information is re quired for every Centerville Ma 02632 11/712020 , _ . page, CttyTown 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 t5 i.diac rev.7128/2018 We 5 Official inspection Form;Subz0aca Sewage Disposal System•Page 1'Ale TOWN OF BARNSTABLE ` I LOCATION Y9 UCH 6 - SEWAGE # VILLAGEC ev % r j/>� � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO._-i 4t,e y� S'�•�/� � SEPTIC TANK CAPACITY r d-6 o i LEACHING FACILITY: ( ) /ifJ�-`! l 1L j a/C r (size). L� NO.OF BEDROOMS��;_ BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: t� . Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � L� 4 7T ZE/ E f TOWN OF BARNSTABLE LOCATION 112 CJC'1('— SEWAGE # �VI✓ �/ V I.LAGE �'C �r �f/I+� ASSESSOR'S MAP & LOST INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /r Q o LEACHING FACILITY: ( ) Z/Z Z— 4 L9«Ukf' (size) NO.OF BEDROOMS . '1 BUILDER OR OWNER PERMITDATE: COMPLIANCE .DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet t Furnished by law A � E 133 No. D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migool 6 5tem Cow6tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System `Individual Components Location Address or Lot No. jf5l,(4 i Nj V 061,. 1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No.�j Designer's Name,Address and Tel.No. � s jwrs sr Type of Building: Dwelling No.of Bedrooms 7— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �3 1k9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ST .,ap 16CAV Type of S.A.S. Description of Soil 6A„o-Q Nature of Repairs or Alterations(Answer when applicable) `I- d1yfi• T� Q GLC. Sion---k_ d ezva2 Cci 6f�. Ul cer�SF�f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance hashed ss'uea y t s lfli7� - Sign d Date Application Approved by Date Application Disapproved Cr the following reaso Permit No. Date Issued No. �V _ Fee l D l THE COMMONWEALTH OF MASSACHUSETTS ` Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppI cation for ligpogal gteM Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) O Complete System "Individual Components Location Address or Lot No. N y V t7D4 Wt Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � S � c�v�s STD Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design'Flow gallons per day. Calculated daily flow u gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Sze',.S`t nh- k0C6; Type of S.A.S. t:- CC, Description of Soil C2LO.� ) f t Nature of Repairs or Alterations(Answer when applicable) vl. d (�)C t 42 ), r !it e-('I. �'W '6 C,, d 4� G f di I G6-�� a . -C,/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance ha&been issued-B`ty his Bre T'li:--- Sign d Date Application Approved by Date Application Disapproved Gr the following reaso Permit No. '' Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded� ' Abandoned( )by &'t —CAA PE� �.. at , «.., has been constructed in accordance with the provisions of Title 5 an the for Disposal System Construction Permit No. ed Installer t Designer r /! The issuance of this p fmi shall not be c nstrued as a guarantee that the ki tem will function as designed. } �0 Date 1 7J Inspector '� v11� It ------)`..----— ------------------ ---------- No. Fee--s���-'�•�-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Zigpogar *pgtem Congtructiou Permit Permission is hereby granted to Construct( )Repair( )Upgrade(L,,)A5andon( ) System located at tdL _<< .� `:�y nc,/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction Austpe completed within three years of the dat of t ' permit. X20 n Date: Approved by ' �' � ��� i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated c� ^ G—� , concerning the property located at �� �'���e� �/pd(� (f45A'--T-( meets all of the following criteria: c4zThis failed system is connected to a residential dwelling only. There are no commercial or business (�uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system !/there is no increase in flow and/or change in use proposed • There are no variances requested or needed. c%he bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �he S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) l B) G.W.Elevation ;A +the MAX.High G.W.Adjustment. , a3, DIFFERENCE BETWEEN A and B SIGNED: DATE: [Please Sketch proposed plan of system on back]. I NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert I U I r y NoS.d .. / ..1�- r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratiou for Uhipuiittl Works Totmtrurtiun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ......... ..... .. ...... mod . - .�.... -T tile................. _..._....... .............._. Location-Address or t No: Owner Address a �% : RJR. Co � , �J D u.►\CH Installer Address Type of Building Size Lot.,d®)_1 .Q.........Sq. feet Dwelling—No. of Bedrooms......... 3.-------------- --------------Expansion Attic (✓j Garbage Grinder (t.A '44 4 Other—T e of Building ��� No. of persons............................ Showers — Cafeteria Otherfixtures --------------------------•-------•---------------------------------•-------•----------------------------------------------------•---------•-------- W Design Flow............. .........................gallons per person per day. Total daily flow..........-33©........................gallons. W Septic Tank—Liquid capac�J-�Q?.gallons Length_-&'_-(e".. Width-�f-°� " Diameter_/ .______. Depth_ " _.. x Disposal Trench—No...AI' ._I'A..._..... Width................... Total Length.................... Total leaching area.............. sq. ft. Seepage Pit No...___/______________ Diameter......1®v__..._ Depth below inlet...... Total leaching areac �o`?......sq. ft. Z Other Distribution box (wol Dosing tank ( ) Percolation Test Results Performed by...... _..00f&Ot ................... Date...____. _ f? .._:.._.._.. Test Pit No. 1 ........minutes per inch Depth of Te Pit.....A........... Depth to ground ater_-- ....... �X, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ---------------------------------------•-------...-----------------......-•----•-------•--•-•------......................................................... O Description of Soil........ __...... t_-`Jbo��— W ......................................! a...... anise..1..-.1��'"'- ....-------------------------------------•----------------------------------------------------...------ U Nature of Repairs or Alterations—Answer when applicable......................................................................................... ---------------------------•-------•-----------------------------------------------............_...--•-.....•••••-••---••------••--•••••-••••••-----••--••••-•-•••-•-•••••--••......•••................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned furpir agrees not to place the system in operation until a Certificate of Compliance een issue y t oard of hgt Si ---------------- ---- ................................ �r Date Application Approved BY •:�...... .--• --••••••.................................•. ............... .... - Dat Application Disapproved for the following reasons:.............................................................................................................. .....................................--------------•---------------.........------------...---•---------••-•••••-••••••••••••••-•-••-----••-----••......-•----•--..................................... Date Permit No.-------- . Issued....................................................... Date Fizis THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................. OF...........:.......................... ' Appliratilan for Disposal Marks Tonstrnrtion Prrinit Application is hereby made for a Permit to Construct (t/ ) or Repair ( ) an Individual Sewage Disposal SysteM at: _ --..........��"�.•-- `�'-�-=--.. '. :+ �. ....................................�!�'. ...........------------............----- ........... . Address 1 e Iv oyLot No.�� G! x ........................ 1-- .. t... ° ...............t. _( 41.-_.1E.............. .. Owner Addr ss ca Installer Address Type of Building Size Lot�9!2� Q_2...._......Sq. feet Dwelling—No. of Bedrooms......... ............•-.-_.-••--_-._--•Expansion Attic (✓) Garbage Grinder (-1A) aOther—Type of Building 4------_---_------- No. of persons...........................:. Showers ( ) — Cafeteria ( ) Otherfixtures ----------------------------------------------------------••-•--•------••-•-•--•----•-----.......---•----------------•---......--------•-...---_..... W Design Flow__.....__.._S __________________________gallons per person >a7 _.__...... . allozow 'Is. 7 th` Pt4 Septic Tank—Li uid capfd ..gallons Length. ............. Width_............_.. Diameter.. _.__.._..... Dep .. ......W. Disposal Trench—'�To____________________ Widt ....... Total Length Total leaching area s ft. x g (j g a •6... q Seepage Pit No.,, _----_- Diameter.................... Depth below inlet.................. Total leaching area..................sq. ft. Z Other Distribution box (. ) Dosing to l�, , a Percolation Test Resu3� n Performed bY.._. F? lcl�Al ..._ -0"IZ nM________________ Date..........._'o � :. ,a Test Pit No. 1..: ._`_.._.._minutes per inch Depth of Test it_______.��_...._.._ Depth to ground ter------- --_--. �T4 Test Pit No. 2_:. <:..........minutes per inch Depth of Test Pit.................... Depth to ground water........................ r •................................................................................................................ O f Description of Soil Cdevl VG 1 xl- •-•-----------------------------------------------------------------••--•--------_---........_.. U --------------------------- �f;� _ Il W VNature of Repairs or Alterations—Answer when applicable................................................................................................ •-------------------------•----•----------------•-------.....-----------------------.......--•-------------...----------•------------------•--•-------•-•-------------------------------------...----•- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned furuiwr agrees not to place the system in operation until a Certificate of Compliance een issue y&t1oard of he t Sin ............................. ................................ Date Application Approved By..... :"-• ........................................... ..............VJZ C'Ir-.— Da Application Disapproved for the following reasons----------------•----------------------------------------------------------------•-------------•---........--•--- .. ...... ------------------••-------------•-•--•----------•••••-----------•--------.....-- ------------------------------ -------------------------------------------------•----- ..................... d Date Permit No. --------- ssue ------------------------------------••.... _..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............................:..........OF...................................................... Tnrtifirtttr of Tompfiattir THIS IS .TO-CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ... '------------------•--•-------- ---------------------------------- •------------•- ---------------------------------------------------------- In;t&ller at............... --••••- ... ..&......................................................... has been installed in accorda ith the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----5.�--a`.-."": .X.17._........ dated- ...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ............................ Inspector---•----. ..-" ---------------------------- l� THE!,COMMONWEALTH OF MASSAC USETTS BOARD.-Of HEALTH Afu N 7-,P ......................... ...............OF...................................................................................... ................ FEE. or ' tr uan rrbti Permissioniis,hereby granted......................................................•---•-----•-------•----••-----------•-------•------••••-•------.............--••------- to Consr -( ) RepQA� Yn Sevcrapoisposal kLbp atNo..................................................J------•---•-•-- street as shown on the application for Disposal Works Construetioi t-^No.16� Dated.._.` -/I:?/`s s---------------- '" ^w p� Board of Health x, DATE "':_ ..�_ . ...................................... %FORM 125S A. M. SULKIN, INC., BOSTON aK, N OTE /f E/TltilGAt. T.+/�SFPTUC TANAC. OR• . ?C. FT M/N if�►Cflliva Pl.T '4Ar4r TNA.N /Z. JZLO tI 9R/4DE0,4 ?4'O/AM.FTER CoovCeETLS COY.E.a! I SNALL gF BaOuGN�"' To 6-4TA r ��iN EX -,CA : CONC.ttTE `' PYC O/Pf i h'EAYY CA ST /RON CG✓ER Si/i4 L Z. BE USED LONERS • M/N. PlTCN •P�Fr. Ar_` j O*DOE f CO h'ER Cl = SA,ti.G e,4CAe LL p>iC C P/P6 O D • • o V • °' Gig i''8 - E +.- /+�!l1V.OlTC/v �_ G/1L. , • • . • • • • • e il a. • •, V4 rT. SEPTIC TANK D/ST. •'• • • • •. • set • • •i WA ShrFO ST',iE • • • . DEPTt/ • • • .� • WASNEA STONE 7 _- i s. • • • • • • PREC,gST SE_,F}gGE INYC/t'T. ELEY�TlGlS/S j�, i cs� ptw c �T y S4� c,� /���+Y • • • • • . • • • • . 0 '• O/7 OR.E41/!Y . s E'L. 9 3 0 'NYeAT AT QU/"MrCr /y o:o FT. /O .SEE T4JVL_A77DIV Ot/74ET SEPTIC TANI{ �FT, INLET .SEpT/rC T.4NX �9� FT . FT O/.41M C C II IN ET 0/S7R/6l?lO/V BOX 99.E FL GROUND P44TER T,46LE SECT/ON O/� �VTIETD/ST�QIB!!T/ON BQ�' `�9. Z �! r . i B SEWAGE G/SA�aSA L YST,� LE`T LEA N! o Z S /y! N C NG !T q fT. 7 LAT! N: ._ - D LEACHING P/T A . DES/G1�f CA TFR/A JCAL.E : %s' _ /=D' DlIyEN.iIOJVITT s D/MANS/ON G a JFT. Al1,v '~ Rd AGE /SP SAL IT Un/E 0 o u�v sL_ SOIL LOG TEST ' TG.TrI L EST/M�f7^EO. FLOW 3 �3 w GA4./DAY S0.1 L TEST AF! SOIL TL�ST402 � SIUMdER G� ACX/NG PITS—L_ 9•'z_._. �EL1�Y. DATE CF do4,1- TEST - I S/oE LC'ACNlNG PER.PlT S:•?. fT. U_ 2 r RESULTS h//Tl4lESSED 8!' xre!P NYE CoN[o11 Jo.TTOM LF�Ci,I/NG.P1•R P!T ?8 �A COLA T/01v RA-rjr�/ Liss M111�I1/VGN OT.�L L. AcH:NG ARE�I Z-•b b ,SO r7 a wa9S o.r L PrNc4oLA'r1a l/!.4TE AZ ;. ��H MIN�IJVCN ?ESE tYE LE�t�iyhV5 A/?E/► z!�6 5t7. FT. . r r Z.O E.• ;;tip'' a _ G,:zA-��L - `Sc�l L TEST P �: 7� $'' , •�a��aA jj1 OFLP ,u - pr �t ReS Rr s� !+fi s ALBERT s� 1 c!LS iEt�GE i o •MoksE cP _ .. iy,0 .;2��7' :' 1 c� 'V6'.ld 51 Q , ` ' EL�R��E7L'E74r./NjnIMs: y ,� /�� rrr,,;�.�'A4�/r�•�P•. � A �n�r1V� � <Cr��cyS.i �.}�.:' <4r� t . r� :t s• � 1 �� c- i �aY:':�,��w"i' �"��- \.'p'Gj �G�S��j2.� �'...� �._ ��'� .fs'•a r:�{�'s[•`'�•t� ♦. .t�,�.. ti.��G 'A � �'�^`",f'..' ^``' � .ENCOt!%YTI�JCEO ; s eLDXXVTf. 4. _ r ' : ��4 v r Y President: Member of: ROBERT BRUCE ELDREDGE.R.L.S. CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS ELDREDGE ENGINEERING MASS.ASSOC.OF LAND SURVEYORS Associates: AND CIVIL ENGINEERS ALBERT A.MORSE,P.E.,R.L.S. COMPANY, INC. AMERICAN CONGRESS ON PHILIP WEINBERG,P.E.,R.L.S. SURVEYING AND MAPPING n / AMERICAN SOCIETY FOR GJ`En9 isEEZE� CRE9 i3tpEZEd TESTING AND MATERIALS land �iviC 712 MAIN STREET s csuavE yoas 2-9inEECs HYANNIS,MASS.02601 TEL.(617)775-2244 Town of Barnstable Board of Health December 18 , 1985 Town Hall Hyannis, Ma. 02601 RE: Lot 34 Valley Brook Road, Centerville, Ma. A visual inspection was made of the sewerage system . installation on December 18, 1985 by Jack McKeon and myself. Large trees are growing near the sewerage system, indicating level .natural ground in the immediate area. The stumps which were dug up and removed by Mr. Driscoll ( 4 truck - loads) per his letter dated December 16 , 1985 (attached) were apparently confined to a small area between the trees. To the best of my knowledge, the sewerage system has been installed in accordance with our sewerage design plans dated September 24 , 1985. Sincerely, ELDREDGE ENGINEERING CO. , INC. Robert B. Eldredge cc: McKeon Custom Design RBE/lld M C KEON Custom Design TO: Town of Barnstable Board of Health DATE: December 16, 1985 RE: Lot 34 Valley Brook Road Centerville, MA Sewage #85-727 The septic system installed for the above mentioned lot is in accordance with the plans submitted. All unsuitable material, specifically stumps encountered between the pit and tank, were removed and good material brought in. This system meets all requirements of the Title V and local codes. J ck Mc Kenn, Builder m Dri oll, Installer P.O Box 545, Centerville, MA 02632 (617) 778-0408 0CA ION SEWAGE PERMIT NO. , YILLAGE INSTA LLER'S NAME & ADDRESS t6�� Soy VIA ���f k, e UILDER OR OWNER 0IA DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED z _ �y _�?!s 2q �3 1 K to !r 45 it 44 • 6Q t ,C :i ttt ( a ti <11 f F l2 790 7. x 7S`� A/.79 "SD "313 W J 0,1i rq 1zS, wivTrl ! (� !`LL �tl I:• The location of any, existing underground sewerage J �rells�, or s shown o other•u.tilit`ien:this. :plan .is 'approx- �r r ,rotate only astdetermined from records and/or verbal � � 20;4.� �4 = z-o 3 n ormatian.}The :conttactor� is responsible for the V" _-- iv��Cification of-,the., existing locations in the field a-7,97 . D -9°� CERTIFIED PLOT PI.AIV n ROBERT -� of 0� I—o7 3 yt VA LG �.y 2C DK ZL�• ` : EL >�L?t' GE y A can/% /�'yi�.�.E• No 19365 IN 50 SCALE, / — .3fJ DATE 7. 3 1 . D Q G 1 .l 4 ICEo N PAN OF A1gs�j EGISTER 0 i IiL01STERED "�"""""'� ALBERT P� I CERTIFY THAT THE PROPGSED, ' , LAND A. �� BUILDING SHOWN ON THIS PLAN M r *. l- 4.< ww�r I g #£NOLNEER ° ` SURVEYOR p(��pYi %`i4;: o MORSE a> 4 J CONFORMS TO THE ZONING LA1WS } + No.10951 � A> ,0 9FcI✓14�'� r OF BARNSTABL , MA S CH.BY' o + TI2�MA1NTR'E.E 9FF �,s 4.J'tp ��A � t�. �nh M-Y N..�,f �.; � kra ���I;�,Aa. ,- ' C..• .�3' - ' tl; -MA$; ► A =,' 3 2 . o DA E REG. LAND SURVEYOR ';,. x .�s. . �► Dt!� ,: � %� '=11 ( 7, ri�..+'gym,r.. i t.... ,Y.�:.�a..�.,•..tl i.e T, a .-,��-:S[.. -1.:X w':�;a.;"r '':r,.2'�'�:#-i�`^,!F fi. .... .,`� '`a ..,���-. - ... .. :},