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HomeMy WebLinkAbout0062 WEAVER ROAD - Health 61 WEAVER ROAD, CENTERVILLE A= 207 083 rir J�RECYttpp UPC 12534 � No.2_ -1_ y � HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco ,0 Owner Owner's Name / information is Cente. Ma 02632 6-25-19 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. Inspector Information s �gvcO on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 c� Company Address Sandwich Ma 02563 City/Town State Zip Code rmv (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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 function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 6-25-19 Dale:A19.9]92 t2:54:W UIOO Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ` �m Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) �u Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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: The system was in working order at the time of inspection. No system design plans were available for property. 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): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 cam, Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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 ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) u- Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 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 ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ R The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �� ,p Title 5 Official Inspection Form IlkSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road (FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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 ❑ Q Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a 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) ❑ E] Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: ❑ 0 Existing information. For example, a plan at the Board of Health. Q ❑ 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: no design plans 3 (total) Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: Number of current residents.. 2 (total) Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? 0 Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): See below Detail: ***2018- 14,000gallons 2017- 15,000gallons*** Sump pump? ❑ Yes H No Last date of occupancy: currentDate l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) V� Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form °I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 2n Sludge depth: 3411 Distance from top of sludge to bottom of outlet tee or baffle 011 Scum thickness NS Distance from top of scum to top of outlet tee or baffle . NS Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wCz 62 Weaver Road(FRONT SYSTEM) u— Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road (FRONT SYSTEM) V Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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): 0" Depth of liquid level above 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c � Commonwealth of Massachusetts �m Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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.): NA * 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: ) n leaching pits number: (1 6'x6' pit ❑ 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 Forth:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts +n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) u% Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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.): The SAS was in working order at the time of inspection. Pit was dry when viewed with no evidence of past back up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form °l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) v Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan):. Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes.below: ❑■ hand-sketch in the area below ❑ drawing attached separately 34 F Water k Servite 24 54 a. r K. 32 30 Rear System Front System I 15 3;7 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(FRONT SYSTEM) V Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ❑E Surface water FMI Check cellar M Shallow wells Estimated depth to high ground water: No GW 10' below bottom of SASfeet 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 El 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: Property sits high in elevation showing bottom of SAS to be >10' above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/201B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts �T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 62 Weaver Road (FRONT SYSTEM) L Property Address Joseph DiFranco Owner Owners Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0■ A. Inspector Information: Complete all fields in this section. ■❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 0■ 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 i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 f, c Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r .t 0 62 Weaver Road(REAR SYSTEM) C-4 try 4r'4 Property Address w+ Joseph DiFranco >, Owner Owner's Name a„`a information is ✓ Co required for every Centerville Ma 02632 6-25-19 page. City/Town State Zip Code Date of Inspection Psi 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. Inspector Information t 390 s on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 Q Company Address Sandwich Ma 02563 a if City/Town State Zip Code 6&j (508)477-0653 S113747 Telephone Number. License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 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 function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails oan.n.a�w�„a� Brett Hickey o.:m, ,�..o.o..,�,d. ®�„���. ..�.w�s 6-25-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Rs c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) V Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: . . 1-" ❑■ 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: The system was in working order at the time of inspection. No design plans for system were available at the Board of Health. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Y Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 62 Weaver Road(REAR SYSTEM) u% Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ 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(l)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) V Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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 i T c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) V� Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El 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 '/2 day flow ❑ El Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 188 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; 62 Weaver Road(REAR SYSTEM) V Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ 0 Has the system received normal flows in the previous two week period? ❑ El Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ El 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: ❑ El Existing information. For example, a plan at the Board of Health. Q ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts �T Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) V� Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 3 (total) Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA Description: Number of current residents: 2 (total) Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes Q 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 0 No Seasonal use? E Yes,�C , No Water meter readings, if available (last 2 years usage(gpd)): See below Detail: ***2018- 14,000gallons 2017- 15,000gallons*** Sump pump? ❑ Yes ❑■ No Last date of Y occu anc current occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 .i Commonwealth of Massachusetts �m ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u � 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 I I Commonwealth of Massachusetts Title 5 Official Inspection Form 1a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed if known and source of information: 9 P ( ) unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 1'6" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ti c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: ■❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 611 Sludge depth: 3011 Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured 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.): The tank was in working order at the time of inspection.The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.726R018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA 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: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 9 Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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): Orr Depth of liquid level above 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 • Commonwealth of Massachusetts �- ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) u= Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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.): NA * 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: (1 ) 6'x6' pit El leaching pits number: ❑ 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 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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.): The SAS was in working order at the time of inspection. Pit was dry when viewed with no evidence of past back up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) v Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Lt5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 i s c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road(REAR SYSTEM) v Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑E hand-sketch in the area below ❑ drawing attached separately ti 34 Y ate Y k Sery 24 Y. 54 32 30 Rear Svstem Front System 37 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 1" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. � 62 Weaver Road(REAR SYSTEM) v� Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ■❑ Check cellar ❑■ Shallow wells No GW 10' below SAS Estimated depth to high ground water: 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 El 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: Property sits at high elevation showing a >10' separation between bottom of SAS and ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i T Commonwealth of Massachusetts Title 5 Official Inspection Form °l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 62 Weaver Road (REAR SYSTEM) v- Property Address Joseph DiFranco Owner Owner's Name information is Centerville Ma 02632 6-25-19 required for every 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. QQ 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 Offdal Inspection Form:Subsurace Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS W DEPARTMENT OF ENVIRONMENTAL PROTECTION r IA 5J'y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property� Address: 62 Weaver Roa//d/ Front S stem Centerville M Owner's Name: Julie Croston Owner's Address: Same Date of Inspection: March 14,2007 Job#07-46 F Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3/14/07 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. Notes and Comments: Tank is not in need of pumping at this time,leaching pit is located under large shrub and could not be excavated.System services kitchen and one bathroom and shows no evidence of backup. . ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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. 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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or I r uneven distribution box. System will ass inspection if with obstructed pipe(s)or due to a broken,settled o u y p p 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: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 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 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 I 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to 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_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 —X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of 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. [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.[ _No_(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. 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. 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) 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 Check if the following have been done.You must indicate"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_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Two years total: 136,000 gal.= 186 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIA L Type of establishment: Design flow(based on 310 CMR 15.203): ON Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding'tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped one year ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 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) _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: Mid 1980's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 BUILDING SEWER:XX (locate on site plan) Depth below grade: I Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:26" Scum thickness: 3" 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: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level is at bottom of outlet invert.Tank shows no evidence of backup from SAS. GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): No solids or hieh stains present. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. 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 is located under a large shrub and could not be opened.Probed stone and soils around pit and found no signs of saturation. CESSPOOLS: No (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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 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. 34 Wat er e S rvice 24 54 Xx �. 18 32 30 Rear System Front System ............»»:::;>:: ......... >::>:;:;::<: ................ ............. .... ............. ....................... ........... ......... ....................... ........ .................................... ......................... 15 37 r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Front system Owner: Julie Croston Date of Inspection: March 14,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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: Low area of abutting property with no surface water is considerably lower than bottom of leaching pit. TOWN OlF RNSTABLE L01'11':TION SEWAGE VIL SAGE J AS,SS SOR'S MA/P'�&,,PARCEL y 1T1 MS NAME&PHONE NO. /a�-i c��6 6,xie 1212 SEPTIC TANK CAPACITY L LEACHING FACILITY:(type) (size) 4 (&�— ) NO.O BEDROOMS OWNER PERMIT DATE: E91!PbfAi EE DATE: 07 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 ° T-- 34 5 Water i 24 Service 54 .......... .. .r..! 1� R 30 32 Rear Sy Front Sr stem s 15 j 37 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A 0.� � W O 1M Syev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ERTIFICA 1 Property Address: 62 Weaver Road (:Rear System Centerville MA CPO Owner's Name: Julie Croston Owner's Address: Same Date of Inspection: March 14,2007 Job#07-46 R Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my, j 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:; a __X_ Passes Conditionally Passes —? Needs Further Evaluatio y the Local A roving Authority r Fails s Inspector's Signature: 1 - Date: 3/14/07 r 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. Notes and Comments:Tank is not in need of pumping at this time,leaching pit has 20-24"of effective leaching. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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. 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: 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: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 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 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. — P — 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to 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_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 _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of 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 1 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. [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.] _No_(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. 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. 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) 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. l / Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 Check if the following have been done.You must indicate"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 Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:4 Does residence have a garbage grinder(yes or.no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):No Water meter readings,if available(last 2 years usage(gpd)):Two years total: 136,000 gal.=186 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped one year ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) _'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: Mid 1980's Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 BUILDING SEWER:XX (locate on site plan) Depth below grade: V Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:. Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of . certificate) Dimensions: 8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 2" ..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: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level is at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels: as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" 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.): No solids or hieh stains present. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March.14,2007 SOIL ABSORPTION SYSTEM(SAS):XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x6 pit. 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.): Liquid level in leaching ait was 20-24"below inlet pine with no sidewall stains above current level CESSPOOLS: No (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 or no), Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2007 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. ........................:'....:..................:::::::. 3 4 ::::::::::.:::..................::.:............................:.:..................................... Wa ter rvi 24 Se ce 54 ...................................... a 18 RMI 32 " 30 ..... ....::::::::::::::'::::::::::................. Rear System Front System X' f a�r.c � E w a b 15 °s u � ' 37 f - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Weaver Road,Centerville. Rear system Owner: Julie Croston Date of Inspection: March 14,2067 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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: Low area of abutting property with no surface water is considerably lower than bottom of leaching pit. TOWN F BARNSTABLEA *e LOCATION SEWAGE # VIL!,,AGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ..�14 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �'.� (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 fee of leaching facility) Feet Edge of Wetland Le ng Faci 'ty (If any tlan exist within 300 f f I n ty) Feet a Furnis d by roz uiev--.r-r FOG 64-pky- F`7 t � \sue pply \µ'` I _ TOWN OF BARNSTABLE A/F LOCATION keo; 444CVAr SEWAGE # L iL VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) !�' (size) NO. OF BEDROOMS S BUILDER,OR OWNER PERMITDATE: 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 Lea g Facility(If any wetlands exist within 300 feet f le g f Feet Furnished b &Z 37 ' 6/26/0 D AT E ; ----------- A 0 ID R E s S 62 Weav-ex Road----_----- Cent-eryille,Mz--s--_- _--- - �7—AbFS 02632 -- - - - ------- ------------ On the above date, I Inspected the septic system at the abov a !VED This system consists of the following; 1 . 2-1000 gallon septic tanks . JUL U 8 2002 2 . 2-Distribution boxes 3 . 2-1000 gallon precast leaching pits . TOWN OFBARNSTABLE HEALTH DEPT. Based on my Inspection, I certify the following conditions: 4. This is a title five septic system. ( 78 Code ) 5 . The. septic system is in proper working order at the present time . SIGNATURE :-, 'Fame Macom_her j J..----- Company ; Joseph-P . -Macomber-& Son , Inc , :. dress : CencBox 66 __--- - r -I-e , Ma_- 02632-0066 pnone 508- 775- 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachf lelds Pumped & Installed Town Sewer Connections P 0 Box 66 Centerville, MA 02632.0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 62 Weaver Road Centerville—,Ma—Ss . Owner's Name: Ronald Pinnell Owner's Address: Same Date of Inspection: Name of Inspector: (please print) Joseph P.Macomber Jr . Company Name: J. P .Macomber & Son Inc . Mailing Address: Ro x 66 Cputeryj Telephone Number: — �—3s02632 CERTIFICATION STATEMENT I certifyv that I have inspected the sewage disposal system at th is 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - Date: The system inspector sha bmit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Weaver Road Centerville ,Mass . Owner-Ronald Pinnell Date of Inspection: 6 26 02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: have not found any information hick indicates that any of the failure criteria described in 310 CMR 15.303 or to 3 S. 4 exist. Any failure criteria not evaluated are indicated below. Comments: Both of the septic systems are in proper working order at the present time . 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. P 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: /VO 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 NDIexplain: A _7 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: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem• Address: 62 Weaver Road entervi e , ass . Owner: Roinald Pinnel Date of Inspection: 6 26 02 C. Further Evaluation is Required by the Board of Health: ,oVP Conditions exist which require funher evaluation by the Board of Health in order to determine if the system is failuig to protect public health, safety or the environment. I. SN•stem 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 wbich will protect public bealth, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is witbin 50 feet of a bordering vegetated wetland or a salt marsh 2. SNstem 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: .L4� The system has a septic tank and soil absorption system (SAS) and the SAS is5 with in 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 I 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 I 0 feet bu 0 feet or morc from a private \Hater supple-ell" Method used to determine distance �./�4lL� •'This system passes if the well water analysis, performed at a DEP cenified 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 anached to this form. 3 Other: 3 Page : of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:62 Weaver Road Centerville .Mass . Owoer:Rona d Pi nnPl 1 Date of Inspection: 6./9A/09 D. System Failure Criteria applicable to all systems: You must indicate "ycs" or"no" to each of the following for all inspections: Yes N�O ackup of sewage into facility or systcm component due to overloaded or clogeed SAS or cesspool f� Discharge or pondtng or effluent to the surface of the ground or surface waters due to an overloadeo or cloggedliquid SAS or cesspool Staticcliquid level in the dismbuuon box about outlet invert due to an overloaded or clogged SAS or cesspool 4NA/&V1i _ ✓ Liquid depth in44+s-p k is less than 6" below invert or available volume is less than ''A day now :�/: Rcquired pumping more than 4 times in the last year NOT due to clogged or obsmvcted pipe(s). Number of times pumped 4' . _ Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any ponion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface fwater supply. Any portion of a cesspool or privy is within a Zone I of a public well. any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but g7eater than 50 feet.from a private water supply well with no acceptable water quality analysis. ITbis system passes If the well water analysis, pert,rmed at e 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,] (Y'cOso)The system fails. I have determined that one or more of the above failure criteria exist as described in �10 CMR 15 30). therefore the system fails. The system owner should contact the Boar: 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 now or 10,000 gpd to 15,000 gpd• You must indicate tither"yes" or"no" to each of the following: tThe following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply 4 the system is within 200 feet of a tributary to a surface dru-Jcing water supply Ithi: system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IV/PA) or a mapped Zone 11 of a public water supply well !f you have answered "yes" to any question in Section E the system is considered a significant threat, or answered es" in Section D above the large system has failed. The owner or operator of any large system considered a s:e.^.:f.cant tttteat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR The system pwner should contact the appropriate regional office of the Department- 4 i Page 5 of I I OFFICIA-L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Weaver Road Centerville ,Mass . Owner: Ronald Pinnell Date of Inspection: 6/26/02 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes Ni//o/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 ? 2_ Were as built plans of the system obtained and examined? (If they were not available note as N/A) _ Was the faciliry or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? JAI Were all system components,Zk—luding 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 ? Z_ 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: Yes no Existing information. For example, a plan at the Board of Health. _v — 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)) 5 Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:62 Weaver Road Centerville .Mass . Owner: Ronald Pinnell Date of Inspection: 6/26/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): J7 DESIGN now based on 310 CT 15.203 (for example: 110 gpd x # of bedrooms): UD%� Number of current residents: Does residence have a garbage grinder(yes or no): ,W Is laundry on a separate sewage system (yes or no):WZ) (if yes separate inspection required) Laundry system inspected (yes or no): f Seasonal use: (yes or no): AZ Water meter readings, if available (last 2 years usage (gpd)): 2000-88 , 000 gallons-241 . 10 G P D Sump pump(yes or no):A)4 2001-86 , 000 gallons=235 . 62 GPD Last date of occupancy:T'jIgh A' COMMERCLAL/1NDUSTRIAL Type of establishment: XJ/� Design now(based on 310 CMR 15.203): �M gpd Basis of design now(seats/persons/sgft,etc.): Grease trap present (yes or no):12.Q Industrial waste holding tank present (yes or no): /� Non-sanitary waste discharged to the Title 5 system (yes or no):lfl� Water meter readings, if available: to Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records , Source of information: Was system pumped as part of the inspection (yes or no)• If yes, volume pumped: _gallons •• How was quantiry pumped determined? Reason for pumping: TY OF SYSTEM _ Septic "distribution box, soil absorption system 40 AA Single cesspool Overflow cesspool Privy WOShared system(yes or no)(if yes, attach previous inspection records, if any) ,�Olnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) /I:f3Tight tank �Attach a copy of the DEP approval A)dOther(describe): dM Appr imate a_o of all components, date ins ailed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no):410 6 1 tom' � � � • THE COMMONWEALTH OF MASSACHUSETTS �9 BOARD OF HEALTH fSil ...............T.own..............OF..........Barnstable No.. .............................................. F'EE... ...2.�.:.00.. -Bi,spnwtt1 MorhB Tun,atrartiunprmit Permission is hereby granted..............J...P.:•Macomber to Construct ( ) or Repair �XX) an Individual Sew age Disposal System at No......J52...W.eauer...Raad...Gen.ter.vi.l-le........................S. ...treet. . .............C ......... pp•• as shown on the application for Disposal Works Construction Permit No.l1�.;�,SQ Dated.......................................... ...............................�.Y...- .........H.. .... .............................. _ �� Board of ealt...h DATE.............. ...... ..... FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................Town..............0F.......Barmstable .... .. .. .................................................. Tprtif irate of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired }�X� by.,l...P...Ma-c amb.ex.........................................................•---......_........................--••--....------------.....................-•----..... Installer at.. We a.uer...Road...C-e-nt.ex.vill.e.......................................... )-----•......................•--•---------------- has been installed in accordance with the provisions of TIT%,E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... �f_-... `�^.U..... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIS ACTORY. // I DATE..................... /.��... 1 .......C{�.�.:....................... Inspector........ =.........................----------•---.......................... 7 I � 1 I \ \ \ r 1 I I I i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No. V........... .. ?0.00 FEE..�....:?.............. Miry aiial vrks (9jrns#rudiun pant# Permission is hereby granted........).P.Ma c ornb e r Jr,. to Construct ( ) or Repair ZX ) an Individual Sewage Disposal System at No........ . ...Weaver Road__.Centerv.. . .ille . --•••-••............ ................................. " •"""""' . .. ....... . Street . . as shown on the application for Disposal Works Constru Permit No .. Dated..... DATE......... Bo of Health .. .I .......................................... FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE &ErIifirate Df (gampliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by .............J....P..mac.Amber....Jr.....................................................:................................................................................................................ ....... . Insmllcr le at ............6.2...Wea.Y..er...Roa.d..."....en.te.r.Y.. .1...... ..................................................................................................... ................................. has been installed in accordance with the provisions of TITLE f The S vironmental C as ibed in the application for Disposal Works Construction Permit No. ......�.... ...... ........ dated . ........c ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONST E AS A G NTE HAT THE SYSTEM ,WILL FUNCTION SATISFACTORY. DATE ....."Z. �2..�....t .........................................................I........ Inspector ........ ................................................................ Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Weaver Road Centerville ,Mass . Owner: Ronald Pinnell Date of Inspection: 6/2 6/0 2 BUILDING SEWER(locateon site plan) Depth below grade: r S ,s:6�41 /J�J' � Materials of construction:,&cast iron d%40 PVC other(explain): 160 Distance from private water supply well or suction line:l9',I Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight . No evidence of leakage The two systems are vented througght the house vents . SEPTIC TANK: Zlocate on site plan)l&EV,x Depth below grade: &T ,� $o Ot>r 74-4,w �aK Material of construction: oncrete,0d metal dfiberglass4 polyethylene y other(explain) If tank is metal list age:,4)P Is age confirmed by a Certificate of Compliance(yes or no):-010(attach a copy of certificate) {� Dimensions: F`i� Sludge depth: /f— Distance from top of s udge to bottom of outlet tee or baflle;/ Scum thickness: Distance from top of scum to top of outlet tee or baffle: /".Gl.` Distance from bottom of scum to botto of outlet teg or baffle:1&i�G How were dimensions determined: 2* �/ii'� Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):_ Pump the septic tanks every 2-3. years . Inlet & outlet tees are in place . Both tanks are structurally sound and show no evidence of leakage . GREASE TRAP/f,d,,u(locate on site plan) Depth below grade: AIA Material of construction:4concrete Wmetal/t,�efiberglasse,&polyethylengMother (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: .rl1,,4 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: _ a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present . 7 Page 8 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Weaver Road Centeryille ,Mass . Owner: Rona] d Pi nnel 1 Date of Inspection: h/2 fi/n g TIGHT or HOLDING TANKi WG(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:AA4concrete,6±_metzlgj,6fiberglass&fi¢ Polyethylene-4/4other(explain): Dimensions: Capacity: Vy allons Desien Flow: —WA gallons/day Alarm present (yes or no):Akh Alarm level: AM Alarm in working order(yes or no): Date of last pumping: AM _ Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: —k/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: NO 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.): Both boxes have one lateral . No evidence of leakage into or out of the box . No evidence of solids carry over . PUMP CHAMBER4,2wQ,(locate on site plan) Pumps in working order(yes or no): Alarms in working order (yes or no): -40 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not present . I 8 Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add ress:62 Weaver Road entervi e , ass . Owner: Ronald Pinnell Date of Inspection: l SOIL ABSORPTION SYSTEM (SAS): l� (locate on site plan, excavation not requir d) Split System. 2-1000 gar�n precast leaching pits . —front one in the rear . If SAS not located explain why: Located ; See page W;0aching pits, number:aching chambers, number: Q leaching galleries, number:Q leaching trenches, number, Iength:O leaching fields, number, dimensions: 410 overflow cesspool, number: innovative/alternative system Type/name of technology:%; 7A-0 (J Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loany nd to sandy loam to medium fine sand , No signs of hydraulic failure or ponding Soi s are ry ege a ion is normal . Rear pit—Waste water is 42 below invert pipe . FrTiri per_ has waste water6l " below the invert pipe . CESSPOOLSPd'.t/e (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet invert:�J}j Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _Cesspools are not present . PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: f� Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present . 9 Pagc IO 0(t OFFICL-L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM fNFOR1v1ATI0N (continvcd) ➢roperr7 Adc,c),:62 Weaver Road Qp—ntervi e , ass . O r: R onald Pinne 0''( of IniPcclico:6 26 02 SKETCH OF SEWACE DISPOSAL SYSTEM PTo.idc t of the "'Ic di'Poltl lyttcm Inclvding ilcs to It Icast two Pc� c✓ incni rcrcrcncc Imncrkc o. ocnchmukl Lo Lo<lic 1II w("I within 100 (m. Locrlc where PvClic witcr )vpPly cnicrt the bvitdint. 20 � I to Page 10 of I I OFFICLAL INSPECTION FORM — NOT FOR VOLUNT,4RY ASSESSMENTS • SUBSURFACE SEWACE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conlinvcd) pfoperery ,,dorc,,; 62 Weaver Road OHocr: Ronald T�xXi e , ss . Dllc of In,p,clioo: 2 SY,ETCH OF SEWACE DISPOSAL SYSTEM Poyloc Ac" c Ikci<h of the Icwlj< dilpolcl lyslcrn Including Ilcl to al Icis1 two permincni rcrcrcncc IanCmark, o, ocn<nmukl lociie ill .+ Ili within 100 (ccl. Loccic whcrc public walcr supply cnlcrl the building. Z Vitay(r Qd I Lov��wv� �`Z C?/o+tir Frc{S�-cti..� 37 ' to Page 11 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Weaver Road entervi e , ass . Owner:Ronald inne Date of Inspection: 26 02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth toground water 20 feet fromt system. Rear system 30 ' Please indicate (check)all methods used to determine the high ground water elevation: from system design plans on record - If checked,date of design plan reviewed: z�W-e t& served site(abutting pro a bservation hole within 150 feet of SAS) 'Checked with local Board of Health-explain: Im Checked with local excavators, installers- (attach documentation)O 7i9w 19S 01/21h E S Accessed USGS database-explain: h t t p ; 11 t own . b a r n s t a b l e ,ma. us You must describe how you established the hi h ground water elevation: Used ; Gahrety & Miller Model. 12/16794 Ground water elevations above sea level . Used ; USGS Qh zerjrati n_lip 11—data. June I A9? Used ; USGS Toc;hpi c- a h„i l -tin 99-000--2P1ate #9 AnDual ran;ses—of—grojind .danuary 1992 Ft-bAj-r 5v5% a r SYs UAC4�rM4 Leaching Pit g,� •-ee t �+� d ` �l a . Groundwater: Feet Below Bottom of Pi gh,G . H� roundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is feet. I1 rrnt+ —nrrT—tr ern.—mrntnrra�en.reer.rrr,:•,tn•nvrr:•r.r-ern+.rn�t.*ra�r.s.rat+ B TOWN OF arnstable BOARD OF IIEALTII 0 SOMS(IRFACF SEWAGE 1)13r'OSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION I•••4••,•T'•.-::._T.rrr.-::-n.r.rm•n:rrrrlre•nrstr r.rr.T•.r-•.'l-1rmr7anRsr TrrtRtsnr llT�re�+7wtn7 tnnn ..r.rrre-. �.-A -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 62 Weaver Road Centerville ,Mass . ASSESSORS MAP, BLOCK AND PARCEL- OWNER' s NAME Ronald Pinnell PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J.P.Macomber & Son Ind''.` COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 790 _ 1578 e� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one ; 2;/Sygtem: PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection whicli I have c 'Ucted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date `?Ix Xnecopy of this ert.ification must be provided to the OWNER, the BUYER re applicable ) and the BOARD OF HIrALT'll. * If the inspection FAILED , the owner or•.1.oporator shall upgrade the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 . 305 . partd . doc I� s a_ Y Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection • .John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 (508)564-684=3 WILLIAM F.WELD Y f Governor ARGEO PAUL CELLUCCI U.Governor 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIC ION mcq 0-1 Lac $3 e Property Address: 62 Weaver Rd.Centerville FRONT SYSTEM Address of Owner: N%9 9*, z Date of Inspection: 4118198 (if different) �FOT9Bl�c ylr Name of Inspector: John Graci Paul McNulty c/o Ann Blackham Winchester,,01 90 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X P8558s This Inepectlon Is based on criteria dented In Tttie v _ Conditional Pa CS code 310CMR16303.My findings are of how the system is performing at the time of the inspection.My inspection does _ Needs Fu er valuation By the Local Approving Authority not Imply any warranty or guarantee or thelongevltyofthe Fails A septic system and any of Its components useful life. Inspector's Signature: Date: 4121199 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "riot determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — Cdlhpllance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 r— i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 82 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty cfo Ann Blackham Winchester 01890 Date of Inspection:411=8 _ Sewaoe backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of offluenl to(Ile a irface of the ground or surface walel5 glue to an Oval loaded 01 clogged cesspool. SAS is in hydraulic failure. (rsvlsed 04r27187) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 52 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspection:4118198 D]SYSTEM FAILS(continued) 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. 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"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revUed 04@71871 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: lit Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty cfo Ann Blackham Winchester 01$90 Date of Inspection:4119199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. ,L 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. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)J (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 02 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty cfo Ann Slackham Winchester 01890 Date of Inspection:4119199 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): Na Sump Pump(yes or no): No Last date of occupancy: Na COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day 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: rda Last date of occupancy: nla OTHER:(Describe) rve Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)No If yes,volume pumped:0 gallons Reason for pumping: No TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(If known)and source information: 1950 Sewage odors detected when arriving at the site:(yes or no) No (revlaed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspection:41181911 SEPTIC TANK: x (locate on site plan) Depth below grade: V Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age Na . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: Le'6"H67"W4'10^ Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 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.) Septle tank and ail components are struchuatly sound and tUnetloning properly.Recommend pumping every two yearn. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:rda Date of last pumpin&. 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: v6,- Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line:l— Diameter: 4"_ Qmments: (conditions of joints,venting,evidence of leakage,etc,) (revlaed 0427S7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 82 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspectlon:4119199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: n1a gallons Design flow: era allons/day Alarm Ievel:_n1a Alarm in working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rds DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)Yea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revlaed 0412718T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 Weaver Rd.Centerville FRONT SYSTEM Owner: Paul McNulty clo Ann Slackham Winchester 01890 Date of Inspectlon:4118►98 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: one 100D gellon leach pit leaching chambers,number:We leaching galleries,number: nia leaching trenches,number,length: rda leaching fields,number,dimensions:nia overflow cesspool,number:nia Alternate system: nia Name of Technology:_rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Leach pit and all components are structurally sound and funclioning properly. CESSPOOLS: (locate on site plan) Number and configuration: nia Depth-top of liquid to inlet invert: rJa Depth of solids layer: nia Depth of scum layer: nia Dimensions of cesspool: nia Materials of construction: oia Indication of groundwater: nia inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nia PRIVY: (locate on site plan) Materials of construction: nia Dimensions: rda Depth of solids: nia Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) We (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 82 Weaver Rd.Centerville BIDE SYSTEM Map 207 Lot 83 Paul McNulty do Ann Blackham Winchester 01890 4118198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) U O ca Q d^ 101 t L E 3 01 o (fie 5LAB 51 co )q AP ` Page ! e! 1D (rwlood 04R7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 02 Weaver Rd.Centerville FRONT SYSTEM Paul McNulty c/o Ann Blackham Winchester 01900 4118/98 Depth of groundwater o Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) Na (revm.doamrar) Pogo 10 0¢ 10 Commonwealth of Massachusetts Executive Office of Envirommental Affairs Dept. of Environmental Protection .titl One winter Street,Boston,Ma. 02108 D.E.Y. Title Grad V Septic Inspector kip P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (501 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PORT CERTIFICATION o Property Address: 62 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot 83 Address of Owner: y�tia�sl 1,99� 1 Date of Inspection: 4/18/98 (if different) F�1419ee P Name of Inspector: John Graci Paul McNulty c/o Ann Blackham Winche ter 4890 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria dented In TRI9 V Conditionally P sses code 310CMR16303.My findings are ofhow(he system is performing atthe time of the Inspection.My Inspection does _ Needs Fur a valuation By the Local Approving Authority not Impyany warranty or guarantee ofthelongevityofthe Fails septic system and any of its components useful file. Inspector's Signature: Date: 4121198 The System Inspector shall s/bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any Information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, Is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04127)97) One Winter Street is Boston,Massachusetts 02108 • FAX(617)5564049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot 83 Owner: Paul McNulty clo Ann Slackham Winchester 01890 Date of Inspection:4118199 _ Sewage backup or.breakout or hi4h.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of he ground or 3ui face walei s due to an over loaded or clogged cesspool. SAS is in hydraulic failure. L(r.111..d(0412797) e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: tit Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot83 Owner: Paul McNulty cfo Ann Blackham Winchester 01890 Date of Inspection:4119198 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. 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] LAR GE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. II tr9v19ed 04271971 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 82 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot83 Owner: Paul McNulty cro Ann Blackham Winchester 01890 Date of Inspection:4119018 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)) (revleed 04l27187) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: tit Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot 83 Owner: Paul McNulty cto Ann Slackham Winchester 01890 . Date of Inspection:411mg FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g'p' Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No last two 2 year usage d Water meter readings,if available:( ( )y g (gp )' rda Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: ma Design flow:0 gallons/day 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: rda Last date of occupancy: nfa OTHER:(Describe) rva Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rva System pumped as part of inspection: (yes or no)No If yes,volume pumped:o gallons Reason for pumping: rda TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 1960 Sewage odors detected when arriving at the site:(yes or no) No (revised 04R7A7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 52 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot 83 Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspection:4119198 SEPTIC TANK: x (locate on site plan) Depth below grade:3" Material of construction:x concreate metal FRP Polyethylene—other(explain) If tank is metal, list age nls . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: LOS°H57^w410" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:g Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:0 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.) Septic tank and all components ere atrueturetly sound end Nnetloning properly.Recommend pumping every two years. GREASE TRAP: (locate on site plan) Depth below grade: Na Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: Na Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle: Na Date of last pumping;de 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.) nfa ` BUILDING SEWER: (Locate on site plan) Depth below grade: 9,, Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linO— Diameter: 4" Qmments: (conditions of joints,venting,evidence of leakage,etc.) (revlsedGUNN?) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: tit Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot83 Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspection:4118198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_POlyethylene_other(explain) Dimensions: nre Capacity: nla gallons Design flow: Na allons/day Alarm level:--On Alarm in working order?—Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rda� Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rVa PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) No f (revised 007197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 02 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot83 Owner: Paul McNulty clo Ann Blackham Winchester 01890 Date of Inspection:4119199 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Na Type: leaching pits,number: one 10M gellon leach pit leaching chambers,number:Na leaching galleries,number: nla leaching trenches,number,length: nia leaching fields,number,dimensions:Na overflow cesspool,number:nia Alternate system: Na Name of Technology:_Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Leach ph and all components as structurally sound and functioning properly. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: nia Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Ns (revised 0411787) t SUBSURFACES EWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 62 Weaver Rd.Centerville BIDE BYBTEM Map 207 Lot 83 Paul McNulty clo Ann Slackham Winchester 01890 4118198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 10 O CQ d Q � 17� o '0I a 0e 5 S A6 [W_ SAP �p 0 pr' Ih u f� page ! of 10 (revised 04AT19T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) 02 Weaver Rd.Centerville SIDE SYSTEM Map 207 Lot 83 Paul McNulty c/o Ann Slackham Winchester 01$00 4118199 Depth of groundwater 12� Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts I (revlsed04)27197) page 10 of 10 ao �/o�3 No.... FizBA....FizB �...30.00- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 62 Weaver Road Centerville ..... -......__ _..........- - --•----•---•------------• --•-----••-----•...---•-•...............•----------•-•-------------.........-•---•................ Location-Address or Lot No. ---Pau 1 Mc Nu 1 ty.................................................. ------ - ............................................................-------------------------------------- 0 ne, Address W J.P.Macomber Jr. Installer Address ,-� -------------------------••----------• -------. - -- .. -------.---------- ----- --------------- ---------------- •---------------------------------------------------------------------------- Type of Building Size Lot............................Sq. feet U Dwellings No. of Bedrooms.........3................................Expansion Attic ( ) Garbage Grinder ( ) �a Other—Type e of Building No. of persons............................ Showers YP g ------------------------•--• P ( ) — Cafeteria ( ) Otherfixtures -------------------------------•---•------------•-•---.------------------------------------------------------------------.....------------------------ W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date.................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -----------------------------------•----....-------------------- -------------------- •--------------- ------- ------------ •------------ ------------------------- ODescription of Soil------------------------------ - - - - --------------------------- ---------------------------------------------------------------------------•------------ W Sand & Gravel V -----------------------------------•------.........••----------------------•----------------------------------•---------•--•--------•-------------------•----------------•-..........------...._...----- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------•--1--1�00.--gallon---pit ---- -----------------------------------------------......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e has bee iss_d b the board f alth. . Signed ---lt..... 4/121 9r0 Dace Application Approved BY ------- . ------- - --------------- Dare Application Disapproved for the following reasons- .............................................----------------------------------------------------------------------------------------- .................... ----...--- -------------------- --------------------------------------------------- ------------- ........................................ Permit No. ..�`� --- - -- ---�-- ---------------------------- Issued --------WDat... ...�.Q........ ----------Dat------ 30.00 No.... .......__...... Fss............._............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Dispnsttl Works Tnmwur#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 62 W.........................•• .......-- .................------•---•-. ...............................................- ......- .._........_.. --- -....... Location-Address or Lot No. ......................al McNla;lt .........................•---------------------------------- W J.P.Ma a omb a t Jr.Owner Address .....................................•-----`..----------.......................................... .......------------------....................................-•----...........................--- Installer Address Type of Building Size Lot............................Sq. feet U DwellingX-No. of Bedrooms..........3................................Expansion Attic ( ) Garbage Grinder ( ) I Other—T e of Building No. of persons............................ Showers — Cafeteria 04 � Other fixtures ------------------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.----.-.-----. Depth................... Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area-.--.---_-_-----__-_sq. ft. Seepage Pit No..................... Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box..( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water........................ (_, Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to,ground water............... ...--.. ----•-•------------------------------ ----------------------- --------- -------------- •------- ---------- 0 Description of Soil............................... x an & Gravel c.� ---------------•-----------------------------------------------•----------•--.----,------------------•-------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when ap licable................................................................................................ ---------------------------•-------•-----...........---•--•---......------------•--j=-1000 gallon.R t.....--------------•-•-.................------------•---•-•----•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hadbDee iss ed by the board of h_alth. Signed i6p .�........ ...................... 12 9 J....----... . Date 1 ( Application Approved By % {../A ... A;- ` ,/l... - -------------------------------------------------- ---------------oa.................. . Application Disapproved for the following reasons- .......................................------------------------------------.......-----.......--------................................ .................................... --------------.........----------------- ��' Date Permit No. ....A--..-...... , ,/�![ Issued .------ 9C� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE %! .er#ifirate of (-omialian.ce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by ............ ....Jr..........................................................------------------------...................----------------......-----....---.....--------------------................ Installer ' at ............62....Weaver.... oad.... .enter-v.. lle.--•------------------------------------------------------__...........-----...... has been installed in accordance with the provisions of TITLE 5-of The St teEVironmental C9de as described in the application for Disposal Works Constction Permit No. 1. dated . I � ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON7,UEAS A G ANTES THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .L DATE--------..-��2... .�.�.................................................................. Inspector --- ....-- ............. ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,- X TOWN OF BARNSTABLE . No..c..! / F�E..�...30.00.. Disposal Works Tnnstrwtinrt "prruti# Permission is hereby granted........! P.Mac omb e r..Jx. to Construct ( ) or Repair )(',X) an Individual Sewage Disposal System at No......_(.?_..Weaver-Road Centerville - -- ! --------•...................................... �j................ as shown on the application for Disposal Works Construction /Permit Street as .... D.at�ed..- .� 1._ .___.... "I�. .�!G.. ...................... ! , Board of Health DATE.--------�----------���-``,,//,,��-1l--•--<................................••----J•/- FORM 36508 HOBBRREN.INC..PUBLISHERS J ` i TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ':-✓�tt�i.�` ��. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.�,T SEPTIC TANK CAPACITY, LEACHING FACILITY:(type) (size)_4a6 _ { NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE 1PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE'GRANTED: Yes No f _` _ E. _ r � -t.,� ® C a -' Y o �' r -- �� /�� rip s � ��-� .,. { ' � •e ® ". e �` ��.. xa 3 4 4 ASSESSORS MAP NO• PARCELNO• No---b /-----•• Fss....Z&O............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uiipuiittl Works Tongtrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..............t� .... ................................ _ rxr..�_}�.............................. L+�2&ss. or Lot No. wn Address �-4 J# 1 Address d Type of Building Size Lot___-____•_•________•_______-Sq. feet V Dwelling=No. of Bedrooms__.....................................Expansion Attic ( ) Garbage Grinder ►-+ aOther—Type of Building ---------------------------- No. of persons............................ Showers (� ) — Cafeteria a'' Other fixtures -------------------------------- . W Design Flow............................................gallons per person er day. Total daiow............................................gallons. WSeptic Tank—Liquid capacity/6V__gallons Length---�......... Width..._`�J'___------- Diameter................ Depth................ x Disposal Trench—No.1Z4 V.._.__..Width...6............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date------------------ Test Pit No. 1___......_------minutes per inch Depth of Test Pit.................... Depth to ground water........................ GX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------- -------------• - ................................................................................................................9 Descriptionof Soil . --------•-•-•---•-•--•---•-•---------•-•-•-•-........................................................................................ W V .............................................................. ---••-•-•----••••-•-----•.......•----••••-•-••---•---•••----•---•-•--•-•-••••---....••-•••-•••••-••--••••-•-•---••--•--••--•-•-•••...•--- W x -------•--------- --------------------------------------- --- ---------------------------------------------------------------------------------------------•------------------•--------------------•--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•-----------•--------------------------------------•------------•------------------------------•----...----------------------------------------•---------------------........-------._....-•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia has en -s ed the board of health. Signed .. ..... ...... ..........'---. .- .. .... - ... .......................... .........-..-....Date.........-...--- Application Approved By --------------------------------------------------- --------------------- -----........................................... Date Application Disapproved for the following reasons- ---- ---------------------------------------------------------------------------------------------------------------------------- ......................................................................................... ..--....--......................................--.........---...........---.---..--..--...----------- .............--.Date.--............... PermitNo. --------- --- --------------- Issued .......----------------------------------------....--- Date A No. Fizic haen............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for 35iipasal Works Tomitrur#inn lirruld Application is hereby made for a Permit to Construct ( ) or Repair. ( ) an Individual Sewage Disposal System at: .............. .� ----------------------------- ------• -I:�................... :�,............................ Location-Addie s or Lot No. ....... _ - /�' --------------------------- W wn Address Pt�.........d.__�d -./V'.�/y/ .... ............................................Address------------...........---.............---- Installe UType of Building Size Lot----------------------------Sq. feet — aDwelling—No. of Bedrooms--_3--_---_-•----•----------------------Expansion Attic ( ) Garbage Grinder 0Zl1—Other—Type of Building ............................ No. of persons---------------------------- Showers ( () — Cafeteria ( ) Other fixtures . W Design Flow............................................gallons per person per day. Total daif Ow................................... ......gallons. WSeptic Tank—Liquid capacity/ /_'?_gallons Length----51........ Width----- _......._ Diameter................ Depth.............._. x Disposal Trench—No. r&7±"a-...._. Width...`............ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- iameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (l/) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--___-__________--_____. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_---_--__--__---______ Q+' ------------------------------------ ----------------------------------------- ------------------------ -------- •------------------------ O Description of Soil_ �; = W ---------------------------------------------------------- --------------------------------------------------------------•-------------.--------------------.................. ----------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.- -------------------------------------------------------------------------------------------- --------------------•----------------------•----------------------------------------------•--•----- ........................................................................... Agreement: The undersigned agrees to install the aforedescribe d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant has be-en sued by the board of Health. Signed . -------------------- ---------------------------------------- Application Approved B ° Daze Application Disapproved for the following reasons: .. ----------------------------------------- ................................................-------------------------- .............................. .-----........-----....----.------------------------------.. ..----------------------------- ........................................ Date PermitNo. ........... ----------------------------------- Issued ------------- -------........-------............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Q-Tertifirate of (fIIutlatian>ce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedep ( ) by-------------------- tall / -=------------------------------Installer tall......--------------------------------------------------- -------------- ------------------------------------ ns atf.. .. .2_sro +• .1( Q.- - ---------- ------------------------ ------------------- ------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... 5...---- -------------------- dated ........................................I------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... 1-0........................................ Inspector ....-------- ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE d-- - No....��.-.1!a.-- f� FEE...... 412....-•--- Dispo.oat 19orks Tunui#rudiun rrutit Permission is hereby granted......... ' ~..... �..___ _ .. ........................°.°. .I.............................................. to Construct ( ) .or Repair (;><T an Individual Sewage Disl5osal System All" atNo.......!...... ......I ...... ...................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No—f-A-..✓_.__ Dated.......................................... ..................................... j ............................................. DATE.......... and of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS • .gyp. TOWN,OF BA,RNSTABLE _ LOCATION (' ItL91 143 � .'_ su+ACE _''_�_' ---- VIL LAG V1 L I_ F _ ASSESSOR'S MAP 6t LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY %G (2 6 S LEACHING F_ACILITY:(tgpe) (size)— w NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT.ISSUED: DATE COMPLIANCE ISSUED: 153,zo) VARIANCE GRANTED: Yes No / y Sn , jv �c i i 30 'S-rMCH .31' ;'_ 1 a©-7 v g3 $ 20 .00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................Town...... .....OF..........$arns.tabl-e................................................ ApplirFation for Uiipoial Warks (fonitrurtion rimmit Application is hereby made for a Permit to Construct ( ) or Repair (XX)C an Individual Sewage Disposal System at: 62 Weaver Road Centerville ................_................................................................................ ----------•--•-.......---._..........------••-•-•----------••---------•------•---•••-------------. Location-Address or Lot No. ----------------------•---•---------------------------•-- .................................................................................................. Owner Address aJ P Macomber-------------------------------------••---•-•••-•..--•--- ....---••-•-•••••---•••...............----........•----•-••-•----•-••-----•---•-•-••--._.....--- Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water................_-_.---- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--.--_-__--___-.--____. ..-•-------•------------------•---••--•-----•--•-----•--•-••---------------•....._----•----•._......•........--••-•----•-------------.... ... •-------------- ODescription of Soil........................................ ------------......-•---•-•--•--------------------------------------------•-------------------------------..---.._......_...._.. x Sand U • -----------------------------------•--•-----•----•-••--•--••-------•---------------•-----•-••-•-------•-•--------------------------•----•--- W ------------------------------------------------------------------------------------------------------------------------------------••--------• ...................................................... U Nature of Repairs or Alterations—Answer when applicable_______________________1-1Q.Q.Q___-gsal l.axL__tank.................... •------------------------------------------•-----------------------------------------------••----••-----••---•-•-•-------••---...i 1QQ-Q--gall-Qn---Pit......••-•-•--•-•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T�p... the provisions of .l.1TTL : 5 of the State Sanitary Code—Th undersigned fur/,ier..arees not to place the system in operation until a Certificate of Compliance has been issue by he a�ofhSigned ------•------••. .•---91U.H......... Date Application Approved By................. ^ S. Application Disapproved for the following reasons--------------------------------------------------------------•------------------------------•--------....._----- ----------------- ---------------------------------------- •-------------- ---------------- ----------------- ------------ --------------------------------------------- •--------------------------•--- Date PermitNo........... .................... Issued...................................... Date FR$.......... -..20.-00 (THECOMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH ........ -----------OF..........BarnAtabl.e---.-----------------................----.------ ApVltr�a# pan fur Disposal Works Toustrurtion umi# Application is hereby�ade for a Permit to Construct ( ) or Repair (XXk an Individual Sewage Disposal System at 62 Weaver Road Centerville ..........................-...................................................................... --....-------•-•-------••--•---------•-------•--------.....----•----------------•----•-------- Location-Address or Lot No. ........Paul McalutX.................... ................................................... ..........--...................................................................................... Owner Address aJ,_ -----P.Macomber ........--•................••---•--_----- --...---._.._._...--------------_----- --..._.....----------------.._.._...._..__. Installer Address PQ 4 `�Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------------------------------------------•-------------......_----•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—'_NTo.____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ 9 -------------------- -----------------------------------------•----------------.._......._..-------......................................................... 0 Description of Soil------------------------------ -------------------------------------•----------------------------------•------ x 5 a rid'-----------•-----•----•-•---•----------- U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•----............ W UNature of Repairs lor Alterations—Answer when applicable-----------------------1-1000 gallon_ tank___________-____-___- ------------------------------------------------------------------------•----------------------•--•-----•---•-----------------.1-].00 0---ga 11 on...P i t.-----.._.........-_.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / Signed tn'!-4 �. !�I, /.�.�//,/l � :.._.. 9/6/88-..._..... / ✓.- r a�i 'J Date Application Approved By--------------Q...e' - r- --d=�- �f /kt �6 ate Application Disapproved for the following reasons:............................................................................................................. ---------------------•----------------•---------------------------------.....--------•----...-------...------------------------------------------------------------------------------------------------ Date PermitNo.......... --..... 0-------------------- Issued__------------------------------------------------------ • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ..........................................OF..................................................................................... T&rrtif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired XX4 by-J„AI-.Naco---L�r-------------- ------•------- -----------------------------------------------------_-------_____-___----------------_______................... at 62 Weaver Road Centerville Installer -------------------------------------- ---------------------------------•-------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... F.?_:...S5_U----- dated...... ................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...----•-••--•----------l ..-.l....-.D--J-•-..................... Inspector............. "SD.............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - Town Barnstable No � Q -- .........................................OF..............----------------------------------------- $ 20. 00 No...G1.�.:._. ..l.S✓ FEE........................ Disposal Works Tontr ion rrmii J.P.Macombe r Permissionis hereby granted.............................................................................................................................................. to Constru6c ( ) or Repair (XX) an Individual Sewage Disposal System b Weaver Road Centerville atNo-_------------ •-------------------•--------------.....-----------------------•----•-•-••----.------------...---------------------------------------•-------------------------..._..--_---_.. Street as shown on the application for Disposal Works Construction Permit No,.*:1s.�__ Dated.......................................... ............................... �.. Y ------------------------------------------ �y_ Board of Health DATE------------- 9 f_"/_..__ ................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS