Loading...
HomeMy WebLinkAbout0071 VICTORIA STREET - Health 71 VI�Cj,TORIA ST., CENTERVILLE 61( m 40 IN UPC 12534 . No.2_ 153LO R �,,, HASTINGS,UN i t TOWN OF BARNSTABLE LOCATION 5 �'' c SEWAGE#4_�, VILLAGE i1 ASSESSOR'S MAP&PARCEL !I tq INSTALLER'S NAME&PHONE NO. 2 SEPTIC TANK CAPACITY �®Q® LEACHING FACILITY:(type) (size) Z 4 NO. OF BEDROOMS w OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY x � y C LO �. /Nc- , No. /�I Z l • T Fee /do, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Disposal 6petem Construction Permit Application for a Permit to Construct( ) Repair(:upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. "�( v\( nG�s� -Q� Owner's Name, nddress,and Tel.No. C *'P1�.Qn1 yliSt O� A1�► t" wa� Assessor's Map/Parcel I�� b`1 \L j, 1o4staller's Name Address and Tel.No.(�0(j 5 6b ID Desi�$n.er's Name, address,and Tel.No. ��b �j� -33 1 6 N D"Gnco�uln o�1 ' �(v. L - t 3M� O psb S�t� a r+�r{ (zach oa�b� p l x °1� C.ki r ,0\,M ff 6"S 31. Type of Building: Dwelling No.of Bedrooms Lot Size ISbo D sq.ft. Garbage Grinder( ) Other Type of Building 1 G1. No.of Persons Showers( ) Cafeteria( ) Other Fixtures n Design Flow(min.required) J 3 gpd Design flow provided L gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank_ /� J o �'( Type of S.A.S. (2�� �c c�^c�crr � SAX�� 9~I`•z� Description of Soil Nature of Repairs or Alterations(Answer when applicable) (Ce& f oV 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 th. Signed Date Application Approved by Date 1 Application Disapproved by T Date for the following reasons Permit No. I Date Issued qa`/ No. fi "(J r Fee 7 r ft� ;.THE COMMONVEA4TH OF MASSACHUSETTS Entered in computer: Yes ✓ PUBLIC`H'EALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS , application for MIsposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(u.-) Upgrade( ) Abandon(') ❑Complete System Individual Components Location Address or Lot No ")I 1( S\A:5 h—U'f Owner's Name,Address,and Tel.No. Assessor's Map/ParcelAl { Installer's Name,Address,and Tel.No.(S06 !ohs- 3(.Q U Designer's Name,Address,and Tel.No. p0(StoK TSO 51A nor( b(00`1 oo tua�l0- b `�`e� C ,g Type of Building: o. Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons n Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 30 gpd Design flow provided t-/ gpd Plan Date - Number of sheets Revision Date Title / Size of Septic Tank /(}0/9 A Type of S.A.S. �� Description of Soil y Nature of Repairs or Alterations(Answer when applicable) C(Q Ck1 f t)(- 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 1e th. Signed / Date (0 !3 la i Application Approved by it ,,�,^ (A,O f ,- " " Date .{4 rb / Application Disapproved by V _ Date for the following reasons s Permit No. d Date Issued �� h THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Eertificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V)-' Upgraded Abandoned( )by "1 or\P::, ,r!r 06..:. t.cy,\ at has been constructed in accordance / t a with the provisions of Title 5 and the for Disposal System Construction Permit No. {�Ydated / � ) f Installer -<. in 0 Cn 0ei_J;a-yi Designer rA e,?Y— S t�"+,t$ n C #bedrooms 3 Approved design flow 3 V gpd The issuance of this permit shall notbe construed as a guarantee that the system Ldesig�neDate �.�. Ins ector .... --- _W - -- -- -----. -•------ ----•----- ---•--- ----•---------------- --•----- i No . r� t�f - 07 1 j t/� `'' { ' #.Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS �n f �,,�- 3 d,; Misposal �ipstem Cons truction.,,,Vermit Permission is hereby granted to Construct( )'' Repair( ) Upgrade( ) 5''Abandon �. System located at ( �k {U 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 orrspecial conditions. ,r Provided:Construction must be completed within three years of the date this permit.ri of/ . - ►� Date �J����, ( Approved by 3. ti Town of Barnstable Regulatory Services i Richard V. Scali, Interim Director BAX `ARM BLUR Public Health Division � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 411 Installer& Designer Certification FormLq )Date: Sewage Permit# aDo1( - Assessor's Map\Parcel � o 1114 �pDesigner: I/1✓�� Installer: �o��,� l Address: 2LT) �l Address: D 3C) J �b W 1 . oYe b�y VI/Lk 62S - 02,S 3�- On � (aJ a i2y7S CX was issued a permit to install a . (date ` / (installer) (� l septic system at �9 1 L�p Lk �'C) 6M based on a design drawn by �// fl (address) W �✓� /" dated 5 - _ (designer) I certify Xthe is p c s stem rle'ferenced above was installed substantially according to roved changes such as lateral relocation of the the design, which may include minor approved distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the I�A._approval letters (if applicable) - or ell— (Installer's Signature) ` 1140 (Designer's Sign e) (Affix er PLEASE RETURN O BARNSTABLE PUBLIC HEALTH 'WON. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc t �tl Town of Barnstable Inspectional Services Department • BARNSI'Ast4 MASS. Public Health Division 1639. Arfp�" 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7021 0350 0000 1549 3884 May 17, 2021 HATHAWAY, STEPHEN J& SCOTT, JESSICA A 71 VICTORIA STREET CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 71 Victoria Street, Centerville, MA was inspected on 04/20/2021 by Christopher Maki, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH cKean, , Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\71 Victoria Street Centerville.doc Town of Barnstable R"w-MA.% Inspectional Services Department ib39• �0 "rf639--l ' Public Health Division 200 Main Street, Hyannis MA 02601 l humas A McKean,Clio Office 508-862-4644 FAX- 508-790-6304 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CM An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA round ❑ Discharge or ponding of effluent to the surface of the g ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE 1 YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A onion of the cesspool is located within 50 feet of a private water supply well p I with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO 2 YEAR DEADLINE CRITERIA ❑ Single Cesspool systems'' (broken cover; relocation of a pipe, relocation ❑ Any "conditionally passed /eaci riveway due to 1-1-10 components, etc) hing facility with standing liquid level at or above the invert pipe (per >own Code §360-20 h) OTHER Repair deadline:_ ----- ----- O.\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS doc Commonwealth of Massachusetts Title 5 official Inspection Form lI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET _ Property Address STEPHEN HATHAWAY Owner Owner's Name — information is CENTERVILLE required for every _ _MA 02632 4/20/2021 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 A. Inspector Information CC filling out forms p on the computer, use only the tab _Christo her Maki _ key to move your Name of Inspector - — -- cursor-do not Cape Cod Se tic Services use the return - -- key. Company Name --- 350 Main St. Company Address — ---- W Yarmouth _ _ — _ MA 02673 City/Town State Zip Code rerun 508-775-2825 TelephoneSI-14423 -- 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 15.000); 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 fun ction 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 r Inspector's Sign 5/3/2021ature 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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 F- �� Commonwealth of Massachusetts P Title 5 Official Inspection Form - ifs) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address A STEPHEN HATHAWAY_ Owner Owner's Name information is CENTERVILLE required for every _— _ MA _ 02632 4/20/2021 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: 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): 15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 t � Commonwealth of Massachusetts = ,7s Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name required for is y CENTERVILLE _____ required for ever _— ______ ________ MA _ 02632 4/20/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET__ Property Address ^ --- STEPHEN HATHAW_A_Y_ Owner Owner's Name -- information is CENTERVILLE required for every _MA_ 02632 4/20/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form — �,iil Subsurface Sewage Disposal System Form - Not for Voluntary Assessments to , 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name information is CENTERVILLE _ required for every MA 02632 4/20/2021 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 %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less tha n 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 5 of 18 Commonwealth of Massachusetts . .M.lp Title 5 Official Inspection Fora 12 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name information is CENTERVILLE _ required for every MA 02632 4/20/2021 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form ,iIl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address S_T_EPHEN HATHAWAY_ Owner Owner's Name information is CENTERVILLE required for every ___________-_— _ MA _ 02632 _ 4/20/2021 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 Description: Number of current residents: 2 Does residence have a garbage grinder. El 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): '20-295 GPD Detail: 19-263 GPD - Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date t5insp doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts }f-- Title 5 Official Inspection Form �;.I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA ST_R_E_E_T_______ Property Address STEPHEN HATHAWAY Owner Owner's Name— information is CENTERVILLE required for every __.__..._._ . ..._. _. . .._. _ _ _-.__ MA 02632 ___ 4/20/2021 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: UNKNOWN _ Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: -- gallons How was quantity pumped determined? --- Reason for pumping: ---. _ 15insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts i11 - ;W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VICTORIA STREET Property Address^-- --- —- -- STEPHEN HATHAWAY Owner Owner's Name information is CENTERVILLE _ required for every _ MA 02632 _ 4/20/2021 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 p known and( ) source of information: 1983 PER PLAN ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 37_— feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ _ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 'V �1� Subsurface Sewage Disposal System Form =Not for Voluntary Assessments c f 71 VICTORIA _STREET Property Address STEPHEN HATHAWAY_ _ Owner Owner's Name information is CENTERVILLE _ required for every — __ _MA 02632 _ 4/20/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 32" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: —� years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLONS Sludge depth: 51' Distance from top of sludge to bottom of outlet tee or baffle " Scum thickness 5 _. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEE AT INLET, CONCRETE OUTLET IN PLACE. TANK AT NORMAL OPERATING LEVEL WITH HEAVY SLUDGE AND SOLIDS. COVERS 12" BELOW GRADE t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET _ Property Address -- -- STEPHEN HATHAWA_Y Owner Owner's Name -� — information is CENTERVILLE required for every ____ __. __ MA_ 02632 4/20/2021 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 7/2a/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts 1 --1 Title 5 Official Inspection Form W) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET_ Property Address STEPHEN HATHAW_AY_ _ Owner Owner's Name information is y CENTERVILLE _required for ever _ _____ MA 02632 4/20/2021 page. City/Town 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 EVEN_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX SHOWS SIGNS OF DETERIORATION t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts +,p Title 5 Official Inspecti®n Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address —— STEPHEN HAT_HAWAY Owner Owner's Name information is CENTERVILLE required for every __. — MA 02632 4/20/2021 page. City/Town 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' ❑ 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 1 -:-- ,`p Title 5 Official Inspection Form l I�, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA STREET Property Address - STEPHEN HATHAWAY_ ___ Owner Owner's Name informatrequired is CENTERVILLE required for every _ _ _ MA 02632 4/20/2021 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.): 1-6'X6' PIT WITH 1.5' OFF STONE FOUND FULL OF EFFLUENT TO WITHIN 6" OF THE INLET PIPE WITH STAIN LINES FOUND AT INLET PIPE. 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.7126l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18I ommonwealth of Massachusetts -:_, Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name information is required for every CENTERVILLE MA 02632 4/20/2021 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 _=== -6P Title 5 Official Inspection Form Iti Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,1_,• 71 VICTORIA STREET _ Property Address ` -- STEPHEN HATHAWAY OwnerOwner's information is CENTERVILLE required for every _..__..____ __ MA_ 02632 4/20/2021 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 0 v 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 t,` Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name -- information is CENTERVILLE required for every _ MA 02632 _ 4/20/2021 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: +16' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from on system design plans Y g p record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: HAND AUGER PERFORMED ONSITE AT TIME OF INSPECTION TO 16' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 10.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp doc•rev 7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts -_, Title 5 Official Inspection Form -� _— ,; Subsurface Sewage Disposal System Form - Not for Voluntary� ntary Assessments 71 VICTORIA STREET Property Address STEPHEN HATHAWAY Owner Owner's Name information is CENTERVILLE required for every _ MA 02632 4/20/2021 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST 00 Property Address h0l GINNETTY Owner Owner's Name information is H required for CENTERVILLE MA 02632 8-3-17 ; every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-3-17 Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 °e7i VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION THE SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. THE TANK WAS PUMPED FOR MAINTENANCE AS WELL. THE SYSTEM IS FROM 1983, FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT. PIT WAS OPENED AND HAD ABOUT 3 FT OF WATER AT TIME OF INSPECTION WITH CLEAN AGGREGATE VISIBLE THROUGH HOLES IN PIT. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , e 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information required forts CENTERVILLE MA 02632 8-3-17 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owners Name information is required for CENTERVILLE MA 02632 8-3-17 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3/13 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 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No s ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. CityrFown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system_received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4per assessing DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3113 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 , 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: A SEPTIC TANK AND LEACH PIT WERE FOUND AS BUILT SHOWS A D-BOX BUT IT WAS NOT LOCATED I PROBED WHERE IT WAS SHOWN ON THE AS-BUILT BUT DID NOT LOCATE IT. THE SYSTEM IS QUITE DEEP SO THAT MIGHT BE WHY I WAS UNABLE TO LOCATE IT. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2015----------142 FOR 1/2 YR 2014---------312.3 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w r� 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: PUMPED IN 2015 AND ALSO 8-3-17 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? TANK TRUCK Reason for pumping: MAINTENANCE 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 co of the current operation and 9Y PY P 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. Att ach a copy of the DEP approval.al. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•''l 71 VICTORIA ST Property Address GINNETTY Owner Owners Name information is required for CENTERVILLE MA 02632 8-3-17 every page.. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: MODERATE t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 PUMPED AT TIME OF INSPECTION FOR MAINTENANCE TANK IS ABOUT 3 FT DEEP WITH A RISER ON INLET END AND A LARGE 36 INCH COVER. TANK WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y~ 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. CityrFown 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 NOT FOUND Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): • If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityrrown 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 ondin , dam soil condition of 9 Y P 9 P vegetation, etc.): PIT WAS OPENED AND HAD ABOUT 3 FT OF WATER AT TIME OF INSPECTION THE EXACT STAIN LINE WAS HARD TO DETERMINE DUE TO THE DEPTH BUT THERE WAS CLEAN AGGREGATE CLEARLY VISABLE THROUGH THE HOLES ABOVE THE WATER LINE.THIS PIT IS FROM 1983. THIS REPORT IS NOT A GUARANTEE OF HOW THE SYSTEM WILL PERFORM IN THE FUTURE UNDER THE SAME OR INCREASED USE. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool `Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 — - J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owners Name information is required for CENTERVILLE MA 02632 8-3-17 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 VICTORIA ST Property Address GI.NNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: INSTALLED SEPTIC 2 HOUSES DOWN AT APPROX THE SAME ELEVATION AND THERE WERE NO GROUND WATER ISSUES Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-3-17 every page. Cityr town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Assessing As-Built Cards Page 1 of 2 t0�#TION7;0�_'/ SEWAGE 9ERMIT.119. VILLAGE ,Ilk *I- (1 IN TALLER'S NAME A ADDRESS A l'a _2 a Ci., ld •-r" - cPe. h off. r�hb BIULDER ON OWNER _4�OATE PERMIT ISSUED '61DATE COMPLIANCE ISSUED, e I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=148046&seq=1 8/3/2017 ��Commonwealth of Massachusetts M H9-Q �p _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST �T Property Address GINNETTY t.., Owner Owner's Name �7 information is CENTERVILLE ✓ MA 02632 8-10-15 required for every page. City/Town State Zip Code Date of Inspection :D 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name VQ P.O. BOX 145 Company Address CENTERVILLE MA 02632 City(rown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-10-15 I Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.does not address how the system will perform in the future under the same or different conditions of use. 4 0 gga vs t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 T \ 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: AT TIME OF INSPECTION THE SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. THE TANK WAS PUMPED FOR MAINTENANCE AS WELL. THE SYSTEM IS FROM 1983, FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 VICTORIA ST Property Address GI NNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 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 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms,(design): 4 Number of bedrooms(actual): 4per assessing DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Tide 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 �M 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: A SEPTIC TANK AND LEACH PIT WERE FOUND AS BUILT SHOWS A D-BOX BUT IT WAS NOT LOCATED 1 PROBED WHERE IT WAS SHOWN ON THE AS-BUILT BUT DID NOT LOCATE IT. THE SYSTEM IS QUITE DEEP SO THAT MIGHT BE WHY I WAS UNABLE TO LOCATE IT. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2015----------142 FOR 1/2 YR 2014----------312.3 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: SCOTT FRANK Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? TANK TRUCK Reason for pumping: ' MAINTENANCE Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness LIGHT Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 PUMPED AT TIME OF INSPECTION FOR MAINTENANCE TANK IS ABOUT 3 FT DEEP WITH A RISER ON INLET END AND A LARGE 36 INCH COVER Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NOT FOUND Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GI NNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown 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.): PIT WAS OPENED AND HAD ABOUT 3 FT OF WATER AT TIME OF INSPECTION THE EXACT STAIN LINE WAS HARD TO DETERMINE DUE TO THE DEPTH BUT THERE WAS CLEAN AGGREGATE CLEARLY VISABLE THROUGH THE HOLES ABOVE THE WATER LINE.THIS PIT IS FROM 1983. THIS REPORT IS NOT A GUARANTEE OF HOW THE SYSTEM WILL PERFORM IN THE FUTURE UNDER THE SAME OR INCREASED USE. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Citylrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: INSTALLED SEPTIC 2 HOUSES DOWN AT APPROX THE SAME ELEVATION AND THERE WERE NO GROUND WATER ISSUES Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ' 71 VICTORIA ST Property Address GINNETTY Owner Owner's Name information is required for CENTERVILLE MA 02632 8-10-15 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater h Sket f® c o Sewage Disposal System either drawn on page 15 or attached in separate file 9 P Y P9 P t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 2 of 2 I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=148046&seq=1 8/11/2015 Assessing As-Built Cards Page 1 of 2 LOCAt1oN �F IMAGE PERMIT.110. , VILLAGE INSTALLER'S NAME A ADDRESS SOLDER OR OWNER O4�I`j DATE ►ERMIT 13SUED Q O DATE COMPLIANCE ISSUED 0 yz 39 i 9 33 I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=148046&seq=l 8/11/2015 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. 41 A- A. Certification Important: When filling out 1. Property Information: / forms on the computer,use 71 Victoria Street- Centerville, MA only the tab key Property Address to move your Vincent Simarano cursor-do not use the return Owner's Name key. 186 Reservoir Street Owner's Address Marlboro MA 01752 City/Town State Zip Code Date of Inspection: June 19, 2006Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 "= City/Town State Zip Code—-' '' 508 364 0894 ='= _ Telephone Number c- Certification Statement: r =� I certify that I have personally inspected the sewage disposal system at this addr j s and that the information reported below is true, accurate and complete as of the time of the inspectiow-The inspection was performed based on my training and experience in the proper function and njiaintendnce of•'o,n site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Lo al Approving Authority • S June 19, 2006 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5-2392.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 l Commonwealth of Massachusetts Title 5 Official Inspection Form 18 Not for Voluntary Assessments Subsurface Sewage Disposal System Form SVe� A. Certification (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iv^M Subsurface Sewage Disposal System Form A. Certification (coat.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM B. Checklist 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Check if the following have been done. You must indicate "yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, including 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(3)(b)] t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 (Assessor) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd design 581 gpd leaching Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 25 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 1 year agoDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): — -- -- t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 i Commonwealth of Massachusetts W Title 5 Official Inspection Fora, Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 22 years. Certificate of Compliance 1130184 (Board of Health Permit#83-1125)) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: 1feet 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 ❑ Yes ❑ No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 12 inches Distance from top of sludge to bottom of outlet tee or baffle 22 inches Scum thickness 0 inch Distance from top of scum to top of outlet tee or baffle 10 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? Design Plan t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M SVe�. C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping required at this time and maintenance pumping is recommended every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction.- El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments r�M Subsurface Sewage Disposal System Form C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the leach pit. t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4�M C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 37 i 31 L)2. , 33 � t5-2392.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments iG M Subsurface Sewage Disposal System Form C. System Information (cont.) 71 Victoria Street Property Address Centerville MA 02632 City/Town State Zip Code Vincent Simarano June 19, 2006 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/13/83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 3.7 feet above the bottom of a witnessed test pit in which no water was encountered. Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2392.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 I = r EC "LU J U L 1 0 2000 TOW".7- '4;TABLE COMMONWEALTH OF MASACHUSETTS hul,, �.`�'T. EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Address of Owner: 186 RESEVOIR ST MARLBORO MA.01762 Date of Inspection: 7/3100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 508-564-6813 FAX 608-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspecteddhe sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection:The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes ! _ Conditionally Passes _ Needs Further Evalua'o By the Local Approving Authority Fails Inspector's Signature: Date:7/3/00 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If th system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of huw the system is performing at the time of inspection.My r inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS AS NEEDED FOR PROPER MAINTENANCE. revised 912/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n(a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or notmetal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed laio ., revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n(a(approximation not valid). 3) OTHER n/a y .4" revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) I Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. - X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. - X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped.Q. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is'within 50 feet of a private water supply well, _ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner: VINCENT SIMARANO Date of Inspection: 7/3/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. z revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): Total DESIGN flow: 440 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: 1/1/00 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: nla Last date.of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1983-PERMIT 83-1126 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 Page 6 of,11 — I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 34" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 36" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 5'7"W 4'10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a I revised 9/2/98 Page 7 of 11 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION('continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a t revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (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: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 Page 9 of 11 Y' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7/3/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) O A C. Ca� 0 /TV y� tic a C 33 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 VICTORIA ST CENTERVILLE, MA 02632 L71 Name of Owner VINCENT SIMARANO Date of Inspection: 7l3/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained,from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) UGSS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 __ I L0 CAT ION-�f71 SEWAGE PERMIT . N;O. VILLAGE INSTALLER'S NAME i ADDRESS A N OLD[ R' • OR OWNER ooG4��- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i Y I f 1 e 'C/C � l jl c r O a3nsS1 13MVIldVJO3 31Va C? a3ASS1 llwua 31Va .� e'1 0 5A9 0 VI NMO 110 N 3010 N �. ssIvaaV Y 3wVN S,V311 V1SN1 39V1 IA 'ON 11MV3d 19VMIS /L NOIiV ���l1 31 33 FEs....���.�� ................. t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...d...�j..�.�...----.....OF_4;.. ... .76.S 4:6.7 ........................ Appliration for Biipusal Works Tonstrurtiun 11amit Application is hereby made for a Permit to Construct (( or Repair ( ) an Individual Sewage Disposal System at: ...._ I.. 1..J�: tti n6d�.ess I No� r .. ... i ......... — ._. ._.. _.....----••-•-•....•---.......•-• -•---•. / Owner "' "'- ' lf dress Installer Type of Buildin Address yP g Size Lot._/.�_.Qj9d_-_Sq. feet Dwelling—No. of Bedrooms.........._3............................Expansion Attic ( ) Garage Grinder ( ) a Other—T e of Building a Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures . W Design Flow............ ....................gallons per person per day. Total daily flow......... .. ...................gallons. WSeptic Tank—Liquid*capacity/0. allons Length.__....'3...... Width.....4_'.... Diameter................ Depth.-..__.......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area. ................... ft. Seepage Pit No......./............ Diameter,` .,'..... Depth below inlet......'....... Total leaching area�� ��. c}.-ft.C�,P,9 Z Other Distribution box (N Dosing tank ( ) Percolation Test Results Performed by...... Date_/__d___---.1. Test Pit No. 1...<.Z..minutes per inch Depth of Test Pit...1 f_"- Depth to ground water/.0:T J_N__ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waterv' - --� 9 ........ ---------------------------------- ........._ ..-•--•-----•---......-•-•-•-------...--•--.....................-................................... O Description of Soil....................C5 ..._______ ' x - •-•••----•••••-•--__...---•-------------•---------••-•.........._ W ...........•--------------•--••-------•-•---...-•---............._....._---••••_---- •-...-----.......------•------......-------•-•-•--•-------........._......__-•-•............................... -••---•------------------ ----•-------------------------------------------------•----•-------•-----•---------------------•---------------------•-----•-•------------------•--•-----•------•--...... . 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 LI'LZ 5 of the State Sanitary C e—T e undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued the board of health. Signed............... . . ............................................................... ................................ Date Application Approved By................... :. /' • . 1-=:12.- ...... •-----•--••---....- Date Application Disapproved for the following reason .__...__ •........................................................•••-•-------_-.••-•••. ............................... .............. Date PermitNo. •_.. issued....................................................... Date Ne - .. -�' No... FE.R 2 U THE COMMONWEALTH OF MASSACHUSETTS BOARD OF -HEALTH �. ............oF..- .fjn,ZS.T�9. .z- E. ,�Jljlliratiou for �i paiial ;ark,6 Tpustrartiun pumit Application is hereby made for a Permit to Construct (X,or Repair ( ) an Individual Sewage Disposal System at: ..........�:-..._V i ...?a:...... .... -s ...1............................. ..... _�-�7....."--•-1 Z _ o lion Address or t,No, ( � Owner �; J address , ----.....7 ......Q1 Ag .....12.-•-•------•"--•-•-----•-"-----"-._ G� }9T. ' (�i !`f ..... /�1......!:..:_..`...............IIJi(� Installer Address Type of Building Size Lot../,57,...Q.Q.(j....Sq. feet .-� Dwelling—No! of Bedrooms...........� Expansion Attic ( ) Garbage Grinder............................ ( ) Other—T e of Building a YP g ------------------•••------- No. of persons............................ Showers `( ) — Cafeteria ( ) Other fixtures ... `----------------•=---------- ............................... ................... w Design Flow.............. ....................gallons per person per day. Total daily flow........... .,�5.Q..................gallons. WSeptic Tank—Liquid capacity l-QGtLyallons Length-----&...... Width......!.... Diameter---------------- Depth.4!........ x Disposal Trench—No..................... Width.................... Total Length..........;......... Total leaching area....................sq. ft. Seepage Pit No......./-----....... Diameter,/0.15.1 ... Depth below inlet....6........... Total leaching areaS.gl.. Z Other Distribution box (A Dosing tank ( ) '-' Percolation Test Results Performed by.-Z.4.W1-. ...WE(,,L,EX.......-!S.1,G,.,-_.. Date./.0.. - __..... a ,.a Test Pit No. 1...<.7,..minutes per inch Depth of Test Pit.../.4f.N_ Depth to ground waterA2P.1.._. ?V...— f� Test Pit 1No.•2................minutes per inch Depth of Test Pit.................... Depth to ground watef G.!Y!v.73F -L7D -•----------•-------•-------•---- -------------- •........._................... -------•----------------------- Description of Soil....... L4 ........- ' . --...•----. ................................................................................................ ,. x c, -•---•--------•--...-•----------•------------------------•-•---•-•----------------•----------•--•••-........•----•---•......•-------•-•----•---------•------•-------......-----•--------•-•---....•----- w UNature of Repairs or Alterations—Answer when applicable...............................:................................................................ --•---•---•--•-•------------------•------••----•--•----•-----•----------..-------..-------------------------------••---------------------•_------ ......... ----------- Agreement: g' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of kI L r Z 5 of the State Sanitary G — T e undersigned further agrees not to place the system in, operation until a Certificate of Compliance has bee - sued the board of health. Signed................. . . ........................................................... ................................ Date Application Approved BY ,'�--------- f.�. �' �� ....... Date . Application Disapproved for the following reason -........................................-............-............................................................ :..._:....-------------------------------•----..........----•--------•----.............................. Date PermitNo................:........................................ Issued....................................................... Date F THE COMMONWEALTH OF MASSACHUSETTS f , e BOARD OF HEALTH .................................I........OF.......................................................I............................. Trr#ff i.ratr of Toutpfiatta THIS IS O CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......... _...._ &...•-•--•••---- ---•..............•---.._..-------•-------•--•---••-------•-•-----•--------------....---........_..--------...............•••-•----•-- at - ' .'�- _.......1 y Installer' ------------------------------------------------------------------------- has been installed in accordance with the provisions of TITI j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-__-_4e_ �ry=__''���-_______ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE 1 SYSTEM WILL FUNCTION SATISFACTORY. DATE. .......... Inspector...................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH N OGf. .... '�r� FEE._ .............. i��roottf ork� Tonstrudi an rrnttt Permissio ereby granted............ 4 :.'-----------------•-----•-----.._..._._.....----._....---......----:.....--•--......-----...... t� Construct cat epatr (, n Individual Seer a Disposal System at No.------- ✓ ie - sue.- c--_ .���' ---------------------•-•- Street , as shown on the application for Disposal Works Construction Per -� •---- -• _ _________B_o-'ard.of Dated ._----------------------------------------- DATE ___---- _-........... ...l -------- Z�:........................... •- -y t. i LEGEND CENTERVILLE o� PROPOSED CONTOUR S 8D ----- PROPOSED SPOT GRADE =" —.—98 -— EXISTING CONTOURR qS -- , + 96.52 EXISTING SPOT GRADE 4^ W— EXISTING WATER SERVICE o wAG � TEST PIT G L. 0 Q��} G� SCALE: 1'=20' S I o LOCUS�� ft. C7��1 T ��� ° v� TA 0'�� d0: EXIST. 1,000G � �E LEACH PIT o _ N 153 cr LOCUS MAP LOCUS INFORMATION / f PLAN REF: 350/055 \ _ �— o TITLE REF: 30813/106 EXIST. 1 ,000E I PARCEL ID: MAP 148 PAR. 046 SEPTIC TANK PROPERTY IN ZONE II, IS IN ESTUARIES PROT. BENCH MARK FLOOD ZONE:E: PROPERTY NOT IN FLOOD ZONE I TOP OF FOUNDATION 1 53.95 111 SEPTIC SYSTEM EX1ST�NG BARNSTABLE GIs DATU \ L�iN� REPAIR PLAN 0 1 �wE LOCATED AT: �\ FNpN 71 VICTORIA STREET \ EoP°53.95+ CENTERVILLE, MA PREPARED FOR G , FT L STEPH EN AND JESSI CA o HATHAWAY G MAY 20, 2021 LOT 12 ,� 11 AREA = 15000 sf+— FT ,1 �� OFsf9� \ PLAN BOOK 350 PAGE 55 yG 1 G ASSR MAP148 PCL 46 D ma M 1 0, M�Y� .� 12, 1 l G " b R DF pAVEME"� E-� MEYER & SONS, INC. 53 EDGE T 1 /��\ SP.O. BOX 981 1 OREAST SANDWICH, MA. 02537 P LA N PH: (508)360-3311 SCALE: 1 in = 20 ft FAX: (774)413-9468 0 go 40 meyerandsonstitle50gmail.com 0 10 20 40 SHEET 1 OF 2 ELEV. TOP NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS { _ FOUNDATION: BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (52.30)• (Existing) � = VENT 53.95--\ F.G.EL 53.0 F.G.EL 52.50 F.G. EL 52.30 . MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 2- OF 3/8" DOUBLE WASHED j F.G.EL• 49.68 + ! 3/4" - 1-1/2' •, STONE OR FILTER FABRIC DOUBLE WASHED STONE 6 " x 4" SCH 40 PVC " aaaa• 0 Mesa . (MIN. aaaaa aaaaa 10 TEE'S ARE TO BE 14 5 ® S= 1% ) aaaaaaaaaaa 4" SCH 40 PVC INV. 48.25 2 EFF. DEPTH aaaaaaaaaaa INV. 48.40 INV. 48.05 4' 2 X 8.5' 4' GAS ,PROPOSED DB-3 DUSTING OUTLET BAFFLE EFFECTIVE LENGTH = 25' .k. ... .,.. .;.,, , . .• ,. . DISTRIBUTION BOX INV: 48.65 (1-120) INV. ELEV.= 47.90 EXIST. 1,000 GALLON SEPTIC TANK OF GAS BAFFLE TO BE INSTALLED ON ���� �ss,��y BREAKOUT OUTLET TEE AS MANUFACTURED BY o DARREN M. ELEV. 48.90 TUF-TITE, ZABEL, OR EQUAL 3 MEYER TOP CONIC. ELEV.= 48.90 ,� 1 " INV. ELEV.= 47.90 a®® , NOTES: r►�sr ° =IF aaaaa a a 1) CONTRACTOR SHALL VERIFY ALL EXISTING ✓ tF` aaaaaaa PIPE INVERTS PRIOR TO CONSTRUCTION Q#ITAR\a� BOTTOM EL.= 45.90 aaaaaaa 2) D-BOX SHALL BE SET LEVEL AND TRUE 3.75 5 FT. 3.75' TO GRADE ON A MECHANICALLY COMPACTED SIX �„� , INCH CRUSHED STONE BASE, AS SPECIFIED IN ` SEPARATION 5.10 FT. EFFECTIVE WIDTH = 12.5 INS CL I LET & O SEPTIC SYSTEM PROFILE 3) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 40.80 _ SOIL ABSORPTION SYSTEM (SECTION} GAS BAFFLE AS REQUIRED (500 GALLON H-20 LEACH CHAMBER). SOIL LOGS P#: 21-129 GENERAL NOTES: DESIGN CRITERIA **IN ESTUARIES PROT.** DATE: MAY 11. 2021 1, ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 3 BEDROOM DESIGN SOIL EVALUATOR: DARREN MEYER, RS, CSE 1614 BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) WITNESS: DAVE STANTON, BARNSTABLE HEALTH DEPT. OF THE STATE ENVIRONMENTAL CODE, TITLE V; AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LAICAL RULES AND REGUUITIONS, EXCEPT AS REQUESTED BELOW: DAILY FLOW: 110 G.P.D. X 3 BR = 330 G.P.D. - 310 CMR 15.405 (1) (B): ate• TP-2 De 1) A 0.40 Fr. VARIANCE FROM 310CMR15.221(7)TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TP-1 Depth Bev. th TO BE UP TO 3.40 Fr(104 BELOW GRADE Vs REWO 3 Fr. (H20/VENr PROVIDED) SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL SEPTIC TANK 52.30 A 0" 52.30 A 0" 3. THE SEWAGE DISPOSAL SYSTEM SWILL NOT BE BACKFILLED PRIOR LOAMY SAND TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE ( )/0.74 = 445.94 S.F. IOYR 4/1 1OYR S4A/F11D LEACHING AREA REQUIRED: 330 DESIGN ENGINEER. 51.63 B 8' " 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING USE TWO (2) 500 GALLON H-20 PRECAST LEACH CHAMBERS W/ 4' 51.80 6 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN B ENGINEER BEFORE CONSTRUCTION CONTINUES. STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D LOAMY SAND LOAMY SAND 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 10YR 5/5 1OYR 5/6 S. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BOTTOM AREA: 25 x 12.5 - 312.5 SF 49.30 36" 49.38 35" THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF PERC TEST - C C HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. SIDE AREA: (25 + 12.5) X 2 X 2 - 150 SF o EL. 47.98 7. WATER SUPPLY PROVIDED.BY TOWN WATER SERVICE. TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D MEDIUM MEDIUM S.ALL AREAS DISTURBED DURING CONSTRUCTION SHUT BE RESTORED SAND SAND TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. DESIGN FLOW PROVIDED: 0.74(462 S.F.) - 342.25 G.P.D. vs. 330 G.P.D. req'd 2.5Y 6/4 2.5Y e/4 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 41.30 1 132" 40.80 1 138" 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. PROPOSED SEPTIC SYSTEM UPGRADE PLAN 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 71 VICTORIA STREET, CENTERVILLE, MA PERC RATE <2 MIN/IN. ("C2" HORIZON) 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY NO GROUNDWATER OBSERVED AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY Prepared for: Hathaway 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. Design and Site Plan by: SCALE DRAWN DATE 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. MEYER 8 SONS,INC. N.T.S. DMM 05/20/21 15. ALL PIPING TO BE 4" SCH 40 O 1/8-/FT (UNLESS SPECIFIED) PO BOX981 REV DATE CHECKED SHEET N0. EAST SANDWICH,MA 02537 508-362--2s22 DMM 2 of 2 ram, o� ) -)C..'AjZ> D{457-- I _ 00 K ti--r- oo A-1 p 7--E e xrsrn9 C7- // CA-1 E�LJf�3G TOPTrC > I2 washed sfone T e° G e Drsr SOX 6'dia. a/OOU CAL. SEPT{C TPIA✓K ?' s hcd .sf o ne a s oa' boo ' TEST FAY: Lod_ . �uJE�LL�2LT��l� Ono P C-we!'. ,rc',,n7 .T L: _...._--____ 1'✓7;/�./;r �,%� ,=';! - ��r�71 �-�-H era..r"`Yh L- 0 LA/ AZI 3 3c, X�ATvN; 5 P'T{C 7-�iv K : 3 3 o x .__._..._ TEST HC7C.& #/ -TE ST 4404.E- pry ` U C_ EfgG'H /lk $ C7T TOM 8r�.•4: �c. �! , o ) - 8 v F i rq 0 t'- i EACH '{ 7 1 N� G AJ o A)e::�i -lE A? A-!e 0 u.v-r-E 2 ED THAT T H C- 8 Cl/L D;N G ! � S E C/V � G & 1�'r L.._. � /`�-! -'�-�--- . Pr2oPo5ED OAJ Tf r-. G•e0UAJD i9S �- LA_ A-/ 0 N 'T f:';,r� >L A N D 0 E S F'0.2 - L 0-T G E 1 GO/t✓F�.PM J-O ?-�� BC}!L.�i A./CG SET- Vr G?"C?.2 i f`3 �' T,� '�.�� ?' THE- rC>GV AJ O F AJ.S T L3 c= G E ti 1 TE 2 L- E Sc 445 SNOt-✓ N z�A7 �.; cE�-,43 ,e /�, r963 t •1= i`/ • F.RCi� H, cr�i � � H;tat;KLEY yr i Nj j�`� "i,rF E- L L_ C? n q c le Vat/o n v T f--I /1i7 legS S. �F eur,2�M� NT5 confOvr-s r cl� s { a �9 �P,QOVED :