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HomeMy WebLinkAbout0067 WATERSIDE DRIVE - Health 67 Waterside Drive Centerville A = 227-173 No. Ael-6 r / Fee ZM THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:�� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . Yes 01ppYitation for XU at *pstrm (Construction 3permit Application for a Permit to Construct( ) Repairade( ) Abandon( ) Lj Complete System Individual Components Location Address or Lot No.67(,v�)`/%�f% � 0ri k: Owner's Name,Address,and Tel.No. Assessor's Map/Parcel %—l �~�r �// Insaller'spNgme„Addrgss,and Ted.No. 0 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /��l G/= /,— �4>� &,Ze4k/fi14' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed e Date Application Approved by Date l p_q / Application Disapproved by Date for the following reasons Permit No. r �T— Date Issued _.0.1. 4- I No. ll�. Fee " THE COMMONWEALTH'OF MASSACHUSETTS Entered in co'm'puter:�1 a PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for MiB Dsar *pstrm Construction Verinit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) Complete System Individual Components Location Address or Lot No.67 4(/14r/%-,f%r /_=J/rl I//__' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel p' 7-� ' � 'y14/-bONnr InstAller'spN4me ddre s,and Tej.No. -09 y2U'9/'3� Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures sti Design Flow(min.required) t gpd Design flow provided I ' gpd � r- _ Plan Date 9V V Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date f Application Approved by Date Application Disapproved by Date for the following reasons Permit No: Q,/t1, Date Issued / 1 ----------------------------------'-- --------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 960114c5 P-6oA Certificate of Compliance ,/r�� THIS IS TO /CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded,( ) Abandoned( )by / .d6i .0,e 6,q'0;"- 5 at ,7 &/.4 rk/^Slk/ V/= CG�,t�re�f//�i/4� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noi- / Ij `7 Q I Installer.!Q/ S�x,Z /JAi"�P� Designer #bedrooms �' Approved design flow�' N/ and The issuance of thij pe t shall not be construed as a guarantee that the system will functi as designed. i Date � ' Inspector ( i ----- ------------------------------------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pBtem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at - ��Nrr-i-Y; and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must :e completed within three years of the date of this pe i` t. - Date Z Approved by I f l� L �, i j 4-- AsBuilt Page 1 of 1 ON ! 0 C A T131� �' 1I S'E A E EERI�IT ND.. c t -- INSTki,LEtt R#k9E A. ADDRESS 6#1 L`@ E R OR OWNER ® ATE PERMIT ISSV'Ep DATE COMPLIANCE ISSUED I 1 1, 1` 2J 'Gr - r 1 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=227173&seq=2 12/20/2016 i I IU.S. Postal ServiceTM(Domestic Mail Only,No Insurance Coverage Provided) Iti IM For delivery information visit our website at wVww.uSpS.CoM8 COCO Postage $ �A N IS nJ C Certified Fee O /Postmark N O Return Receipt Fee p (Endorsement Required) J ! 0 Restricted Delivery Fee !, (Endorsement Required) rag O Total Postage&Fees $ rq Sent To DpriGe bbn/1� rl ----------------------------------—.................................... 0 Street,dpt.No.; 111/, n N' or PO Box No. ¢-x-Kay---51.a. City State,ZIP+4 �[-LLL...CII ...... .....................—_.______ l�lL&d * D30�p PS Form :0r August 2006 See Reverse for Instructions Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■. Certified Mail may ONLY be combined with First-Class Mails or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee„a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS:,Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present.it when making an inquiry.. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONSENDER: COMPLETE THIS SECTION F—CO—MPLETE THIS DELIVERY ■ Complete items 1,2,and 3.Also complete A igna e item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. eive y(Printed Name) C. Date of Delivery ■ Atta6h this card to the back of the mailplece, or on the front if space permits. D. Is deliv address different from item 1? ❑Yes 1. Article Addressed to; if YES,enter delivery address below: ❑No Dorlre Na'-bom-e po ,5ox 5ia N& N V h(l� of l N� 030�D 3. Service Type vV Certified Mail® ❑Priority Mail Express'" Cl Registered )BIReturn Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 2' 7012 1010 0000 2847 8223 I PS Form 3811,July 2013 Domestic Return Receipt UMTED STATES FPWO'a4RVlCE First-Class Mail Postage&Fees_Paid f . NOV'".ski USPS FM :. w. Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4®in this box* aOt) ynaa� I �'EKE ram, Town of Barnstable Barnstable Regulatory Services Department ft'�c j BARNSCABLF- ' " Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8223 November 9, 2016 RE: REVISED Dorice Narbonne PO Box 512 New Boston,NH 03070 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 67 Waterside Drive, Centerville,MA was inspected on 10/05/2016 by David B. Mason, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted and it appears that the tank is leaking. 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 Thomas McKean, R.S., CHO Agent of the Board of Health I Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\67 Waterside Drive Centerville Revised Letter.doc Commonwealth of Massachusetts ,� G°�� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is Centerville MA 02664 October 5 2016 required for every � page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information d on the computer, " use only the tab 1. Inspector: 1 U� I key to move your t� cursor-do not David B. Mason use the return key. Name of Inspector David Mason r� Company Name I 4 Glacier Path f Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Z�X� U&-UU4---1j October 8, 2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. Cityfrown 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: 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): The observations in this inspection represent the condition obwerved only on October 5, 2016 at noon and does not represent the future operation of the system. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 k Commonwealth of Massachusetts W Title 5 Official Inspection Form ?° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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): Roots are growing into the bottom of the distribution box. dbox was observed empty. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5 2016 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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 c,M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information fo is Centerville MA 02664 October 5, 2016 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems?The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2014; 25,000 gallons and 2015; 24,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is Centerville MA 02664 October 5, 2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cM 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: constructed in 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: 3 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.): 1 Septic Tank(locate on site plan): Depth below grade: 12 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 Typical Dimensions: Sludge depth: 8" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent is 10 inches below outlet invert. Tank is 12 inches below grade. structural integrity of tank unknown. 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-3113 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 ;M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is Centerville MA 02664 October 5 2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. CitylTown 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 No liquid 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.): Dbox is empty. Dbox is filled with roots. Dbox is deteriorated and needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M10 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit is 48" below grade. Riser is 24 inches below grade. Effluent level is O. Stain line is approximately 36" down from invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is Centerville MA 02664 October 5, 2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive M Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 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: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �rdv+ ` Qi f3 3 a� a o X-Toj y 3 30 3.D .o CERTIFIED MAILT.. RECEIPT Ir (Domestic Only; r-3 For delivery information visit our website,at www.us to t C` I I _ N CO Postage $ ru Certified Fee ,5.+ '`se•°°� 41. Postmark O Retum.Receipt Fee a p (Endorsement Required) Here Restricted Delivery Fee (Endorsement Required) M Total Postage&Fees s ru / �0 ra .Sent o 1 r�C..e .i b e Q,r onme Street Apt.No.: ` ------------- or PO Box No. --------------------------------------------------------- City,State,ZIP+4. r �oS�^ l �, ]------PS Form ���---- :00 ANuggst 2006 ') NIY�7 Certified Mail Provides: ■ A mailing receipt s A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Maile. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ■ For an,additional fee, delivery may be restricted to the addressee or addressee's aythorized agent.Advise the clerk or mark the mailpiece with the endorsement''Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is'hot needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02-000-9047 I SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Si 17 item 4 if Restricted Delivery is desired. XAgent ■ Print your name and address on the reverse ddressee so that we can return the card to you. B. eived y ipr—ej Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, ,Z$ or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I pbrlGe �fa rbo(7(1 Fb 50X orl O"L A//1 i�► 60 G 1 r)l / v N 3. e Type V CAW ertified Mail® ❑Priority Mail Express' ® L-3() 7-0 ❑Registered Weturn Receipt for Merchandise ❑Insured Mail "0 Collect on Delivery" 4. Restricted Delivery?(Extra Fee) ❑Yes _I 7012 1010 0000 2847 8049 I PS Form 3811,July 2013 Domestic Return Receipt 11 UNITED STATES I�,,, R�A'istVICE First-Class Mail Postage&Fees Paid USPPermit No.G-10 • Sender: Please print your name, address, and ZIP+4®in this box* I Y 1 �r Town of Barnstable Barnstable, Regulatory Services Department AlAmIicaC j "639: ,�� Public Health Division a 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8049 October 20, 2016 Dorice Narbonne PO Box 512 New Boston,NH 03070 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 67 Waterside Drive, Centerville,MA was inspected on 10/05/2016 by David B. Mason, 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 pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1). The distribution box is rotted and appears tank is leaking. 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 OARD OF HEALTH homas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\67 Waterside Drive Centerville.doc f Town of Barnstable + annrrsresr.E, + a & � Regulatory Services Department Ufa� Public Health Division 200 Main Street, Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑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 ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well 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 ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation Gof a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) (A 44vlre- , A (.-dc d1°,1 fc.11 on � Repair deadline: �-4c'a r X Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc i 2 3 r Commonwealth of Massachusetts �O? I e . W itle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ec°M 67 Waterside Drive Property Address Dorice Narbonne ca Owner Owner's Name F+ information is G7' required for every Centerville MA 02664 October 5, 2016 J . page. City/Town State Zip Code Date of Inspection CO x W Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason rQ Company Name 4 Glacier Path Company Address r East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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 zb�—��e October 8, 2016 Inspector's SignatM 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 �o VS i Commonwealth of Massachusetts `Title* 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 5 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is Centerville MA 02664 October 5 2016 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): The observations in this inspection represent the condition obwerved only on October 5, 2016 at noon and does not represent the future operation of the system. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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): Roots are growing into the bottom of the distribution box. dbox was observed empty. ❑ 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 Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title' 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ears usage d Yes 9 ( Y 9 (9p ))� Detail: 2014; 25,000 gallons and 2015; 24,000 gallons it Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title' 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: constructed in 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'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.): Septic Tank(locate on site plan): Depth below grade: 12 inches 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 Typical Sludge depth: 8" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title* 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne _ Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent is 10 inches below outlet invert. Tank is 12 inches below grade. structural integrity of tank unknown. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 _October 5, 2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. Citylrown 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 No liquid 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.): Dbox is empty. Dbox is filled with roots. 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 W Title' 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6 foot pit with 2' stone. effluent up to inlet pipe with staining above. leach pit is 48" below grade. Riser is 24 inches below grade. 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 W Title' 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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 °M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 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: 18 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: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map 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 W Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Waterside Drive Property Address Dorice Narbonne Owner Owner's Name information is required for every Centerville MA 02664 October 5, 2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 1 1 1 1 Qi Q 3 a� ao y 3 3� 3-D rt� -7 7- L 0 1 CAT ltNOR-3` lj-1131lb 1-73 SEWAGE PERMIT NO. R EClm- INSTA LLER'S DAME ADDRESS IDUILDER OR OWNER 0 A T E P E R MIT I S S U E D DATE COMPLIANCE ISSUED f 1 � e 1 f � ,i-� 1 � � , , � , � ��-� ,� i l . � .. } i o cv�Tc25��� ��, -73 No....... ._... ......... THE COMMONWEALTH OF MASSACHUSETTS 11I13 �b BOAR® OF HEALTH d .........OF.... Appliration for Dispoiial Works Tomitrurtiuu ramit Application is hereby made for a Permit to Construct ( -�'or Repair ( ) an Individual Sewage Disposal System at: SI. ._.. 1 .............................•• -•----••----....---....---' O� .�------•--.---------.------•----•--•----------. Location-Address or Lot No. ----------------- -- - •- Owner Address sSf4� Y�1.•J .L��`.. �f, nJtJ �Y/� loz -�-- Installer Address Q Q Type of Building Size Lot./ .....7.........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p`4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow..............`— _..._..............gallons per person per day. Total daily flow---------;5!_,�®......................gallons. WSeptic Tank—Liquid capacity/C��gallons Length..----......... Width...!30_� `.. Diameter................ x Disposal Trench—No. .................... Width............._..__.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------/.......... Diameter.._./ .__..... Depth below inlet................ Total leaching area....652.sq. ft. Z Other Distribution box (44—' Dosing tank ( ) J ~' Percolation Test Results Performed by._� 4�..ate_..../^J..e.6............... Date----1/Z t:1 ............. W .. a Test Pit No. 1...... 'Lr ninutes per inch Depth of Test Pit../_. 2_... Depth to ground water........................ 4A Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G4 .....................................................);...................................................................................................... O Description of Soil......4? C .......................................................... W VNature of Repairs or Alterations—Answer,when applicable.._____......................................................................................... ------------------------------------•----........-------••-•---------------.......---••-•------•-----------------------------------------"--------------------------............---•-----------•••••---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLLi 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance een issued Zthe raf health. Si -------------------- ��'=0 . _ Da Application Approved By............... ......... -=---- ..._..... ........ �o Da_ Application Date Application Disapproved for th llow g reasons- ------------- -------------•-------•---------------•----------•--------------.-------•-------------------•---------------------------•---------------------------------------•---------------------------------------- Date PermitNo......................................................... Issued....................................................... :.. __ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH © ' `-1 oF.... =�f7nJS; ?,;;Gam' ApplirFatiun for Diopootal Works Tonotratrtion 11amit Application is hereby made for a Permit to Construct ( -ro-r Repair ( ) an Individual Sewage Disposal System at: .-•................................................. ............................ ................................................ Location-Address . G o. ..)..,_/ 4 0. -. L.,C . 6 / 4"'a orj t_ ,F 'le ,i/,�i ........ _...................`. •---.................._................... ...................................................................... Owner Address ........_........... a ........................... 2.;.....`a� �r ) ---- --- Installer Address Type of Building Size Lot______/ls/____.........Sq. feet Dwelling—No. of Bedrooms............. ...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -----------•----------------=-------------------------------------------------------------------•--------------------------------------------------- d W Design Flow.........:....S_5 ...................gallons per person per day. Total daily flow---------;- _342.......................gallons. WSeptic Tank—Liquid capacityA allons Length... .....:__.. Width.._'---------- Diameter................ Depth.�__5.... x Disposal Trench—No. .................... Width........,........... Total Length..............._.... Total leaching area....................sq. ft. Seepage Pit No...... .......•-- Diameter....� ......... Depth below inlet......2 ......... Total leaching area....S':_':?.sq. ft. z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.. ....... ........ .'}. .........':'_C.................. Date........................................ 14 Test Pit No. I...... !C _:_minutes per inch Depth of Test Pit___ _ ? .:._ Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................__. Depth to ground water-_-_---_-__..-_--_--_-_. C+ ------•-••--------••--•-•------------•-•.........................•-••--••---•--••-•......_........_............................-•---•---------.....-------- D Description of Soil.......-e-�--•-• l2- '�!" ?:-r - ; �r>J S c�'-c /2 ' /?? '. ............•••••-- - -----------------------------------------------------------------------------------•-----•--------------------....------------------------------------------------------------------------------•----•-- 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 TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has'bee`n issuuede 'by the boa.rd-of health. Slg.r r� ..... .....�._.,-------- c? Q,,��•.... ...._..............____________.________.. _____ �"`'. ApplicationApproved By..................---------....................------------------------------------------------ �_�:.._...._._ / � Date Application Disapproved for the i owi reasons:...............................................................................-•-.........Da.t.e.............. ---------------------••--•-•-•--•--•-•--.............--••.........•----•-•-•----•-------•._._........-••---------------------........------------------. ............................................... Date PermitNo......................................•---•----------•-.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.............................................................I...................... Tntifiratr of ToutpliFanrr 1' TO C�FY That Ir1, 1 idual Sewage Disposal System constructed ( or Repaired ( ) by-Z- --........................•-- ------------•--------------------•--•--------•---•----.........-•---------.......----...-----------•--------- �+ Installer at �!16`fir`-- •-------•----------•-------• ---•-------------•--------•-------•-------•--------.... ---, ----• --•--------------- has b- n installed in accordance with the provisions of TITLE 5 of e State Sanitary.Code �d ri ed in the application for Disposal Works Construction Permit No.....Y .............................. dated-..... ��._(s_ ............................. THE ISSUAN OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM W1 F TION SATISFACTORY. DATE -� -- •--- -----------------•---...............--•---•-----.... Inspector._...--- . ...................................................................... d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH X ..........................................OF..........No................ FEE........................ Bii�rolia' , ur�,^�n Qonstrn ffon rrmit Permission is herebyranted_.._.✓ � �(` --- g to Construct ( _o '' gpai ( ,t f ndi dual S .&,agg' isposal System at No............. ..'...........•-- = ...... w `�C Street as shown on the/Iica ' n for Disposal Works Construction Permit No.--:,,-._-- -. te-d- :._.. ................ •-----. -• ---•---------•---•---•--•-•--•......_....-•-•-•......_ d of Health DATE...�---- ...............................•----------•---- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS �f! SET 20 �f I77%r7. fop o f fou d _ ��. . t r ,(v conc• y� cover-5 2"' layer ,of r 4"Cast iron o/- Sc%. 40 PVC- pipe /2"Irta9C. GOnG• �8N_ �2n rain. pitch ,� cover wa she cr' per ff: . -- ._. �¢ Sch. zo PVC- pipe peasfor�e. n: pitch /g"per"ff f/ow line G E T�?vac. �D,G� _ � �'�#.. —•-- � ,• irrv. e/. 3O2 inV. C/• ate' „• . . • L O G A T/ON Mff?P S�o �9 //C inv. a/. inv. e% •• 3 "- r ,� /.. • � , Stor,d precA sf' .o �, .. to n._ SEt�t/AGE SYSTEM PROF/G. E• bor� ••�•• o 40 a ui✓a•%nf• 3, 10 9rot�nd water fable G/. � ; 3 Li --- b 3� ofj�o�rf Pest l7o/e eta 3 l+ Cr7 En7 4,0 7"s . a A T H "T S T` H U G. � Z_ o G NUMBED OPi SaA��2oOMS 3 TEST OATS : r rc'�S�fr"✓�-} ll'S GArf'BA6E OISPoSf�G. UAJ 1.4GV/TNT SSE1� BY : "d. �7 Sfl�c v!""'P�T. �r-��ti'��.�pt, LER eft q RIG19 f _ ';"�. 1� f'E�E?GOLAT/Oil! �2FIT� : 1 �' M/A!. //A/CA4 " •�-• � � / TOTi9L EST/MATEt� FLOW o ; . CJA2 GAL. Be. OAY x -+ Be) : HOLD Rap. SEPTIC- TANK GAPAGITY: �/h/� � 1 HOLE• Z vy <.L r4> r�ir✓fig ° ( GAd... es/.= s ` I jt_ f1GTURC. SE-PT/G TANfc,- fi'' ;F, , ;f. . \ � � LEi9EN/NGE F1�eEA �EQU/�eEMENTS: ,, w1L 41, a ' all 72 TOTq L t3s fill' �Nl tgNl LE'09GH//VG CAPACITY O7 ' " •+.. "f�/it 'r",F 'V.--. / - - i NOTE WO.eKMA/VSH/P /qNp M/9 TE)e I A G-S _. ..._ _- " '_ ••„Z£s' SHA G.L CCNFO�E'M TO O•E. Q. E T/T G.E $ANO THE TOW/V OFT, �-t' �G , �eaGULMT/owS FOB .- OP l� •` """`-'-- '"' �` SRN 2) Gompi- A/VCE LAI/TH ZON//VG �P.EGULf�TiONS Jy _ .._ ``_ /.S //VSPrECTOje GOMM/SS/ON6�e. EXIST/IVG SHALL 12EMA/A/ ESSEII./ / [-L 'T A Y THE• 4B 0• OF HEA [_TH AGENT -4 G OA J S TRE' UG T/O" - e— O G.A T/O A./ A5- `� SITC P4- A N Pie f'A �e D FOA=- 3a' LEG61VG S G A L E fir�L� UA T E - 2ez-Z. ,,/Z% , f B"�i St%r7 S of C/e✓.a 0.0 e�LiStin9 Contour �s�' �Q s , � /G I��.7 a -typ. prop. prop n. Gon*ovr = e o OI�:�F!1 i �:� c p _ > GA1r1Pt 3 P P' tio. 2:d7T 1 c> > 4 J .3 A 0 ♦/T� / *est hole /oc-ix*iorJ >f , 7 �r S o. LD E /VJV/,S , - �. . M A s s. o z � � o r