HomeMy WebLinkAbout0037 WEDGEWOOD DRIVE - Health 37 WEDGEWOOD DR.
CENTERVILLE
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r.M
37 WEDGEWOOD DR I'Q
Property Address
BOUTIETTE
Owner Owner's Name
information is
required for CENTERVILLE MA 02632 7-10-17 ;
every page. Cityrrown State Zip Code Date of Inspection r Ml
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 A. General Information
forms on the
onlycomp the tab key r,use 1. Inspector:
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
(( � CENTERVILLE MA 02632
I Cityrrown State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-10-17
Inspect Signature. Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
THIS REPORT IS NOT TO BE USED FOR DETERMINATION OF BEDROOMS OR DESIGN
FLOW. THE SYSTEM WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION, BUT A SONO
TUBE FROM THE DECK WAS RESTING ON THE OUTLET CORNER OF THE TANK AND THE D-
BOX APPEARED TO BE UNDER THE DECK AS WELL. THE TANK WAS OPENED AND THE
OTHER COMPONENTS WERE VIEWED BY CAMERA EXACT LOCATION OF OTHER
COMPONENTS COULD NOT BE DETERMINED BECAUSE NO ONE UPDATED THE AS-BUILT
CARD AFTER AN ADDITION WAS PUT ON THE HOUSE.CLEARED TO PASS BY TOM MCKEAN
7-21-17 9:00 AM
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins 3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
a v r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
SONO TUBE FROM DECK IS RESTING ON THE CORNER OF THE SEPTIC TANK OUTLET AND
THE D-BOX APPEARS TO BE UNDER THE DECK. THE S.A.S. AND D-BOX WERE VIEWED BY
SCOTT FRANK WITH A CAMERA. THE SYSTEM WAS FUNCTIONING PROPERLY AT TIME OF
INSPECTION.CLEARED TO PASS BY TOM MCKEAN 7-21-17 9:00 AM
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M bvey`er 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'' 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A
4 BED S.A.S OF HI CAP INFILTRATORS.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
2015-416 2016--159 GPD SYSTEM IS NOT DESIGNED FOR USE WITH DISPOSAL IF ONE IS
PRESENT IT MUST BE DISCONNECTED IN ORDER TO PASS.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: SEASONAL
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '< 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
S.A.S 2001 BY ELLIS BROTHERS
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 PER AS BUILT
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'< 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKED CLEAN AT TIME OF INSPECTION. IF TANK HAS NOT BEEN PUMPED IN THE
PAST 3 YRS I RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE
AFTER FOR MAINTENANCE.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/3 1 Title 5 Official Inspection
Offi sped on Form:Subsurface Sewage Disposal System Page 11 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
BOX WAS VIEWED BY CAMERA BECAUSE NO ONE UPGRADED THE AS-BUILT CARD AFTER
THE ADDITION WAS BUILT. IT APPEARS THAT THE D-BOX IS UNDER THE DECK BUT I CAN
NOT BE 100 PERCENT SURE.WHEN VIEWED BY CAMERA THE BOX WAS FUNCTIONING
PROPERLY.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NO OBSERVATION PORTS LOCATED
t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: HICAPINFILTRATORS
❑ 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.):
12X41 WITH HI CAP INFILTRATORS. NO SIGNS OF FAILURE IN AREA OF S.A.S. THE
OBSERVATION PORT COULD NOT BE LOCATED DUE TO IN ACCURATE AS-BUILT.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owners Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is CENTERVILLE MA 02632 7-10-17
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: GREATER THAN 5 FROM BOTT OF
SAS
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
DESIGN PLAN
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
L
Assessing As-Built Cards Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 37 WEDGEWOOD DR
Property Address
BOUTIETTE
Owner Owner's Name
information is required for CENTERVILLE MA 02632 7-10-17
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=189145&seq=1 7/18/2017
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE / v
LOCATION��' D �02 _SEWYA/GE �l t b
VILLAGE�p „ y ASSESSOR'S MAP&LOT
INSTALLER'S NAME& PHONE
SEPTIC TANK CAPACITY /000 4 j4410)v
LEACHING FACILITY-(type)_ Vg a, 5 (size) MXt�-�
NO.OF BEDROOMS 41 PRIVATE WELL OR PUBLIC WATER I,6.
BUILDER OWNS . [ �d 1✓O
DATE PERMIT ISSUED: S-Z 3—
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=189145&seq=1 7/18/2017
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map I Parcel 'C Application #
Health Division Date Issued
Conservation Division Applicatio
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/Hyannis
Project Street Address
Village
Owner Address
Telephone (Jr-al?) y�
Permit Request Atzyz L
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation _5 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Fdl ❑ Crawl ❑Walkout ❑Other
Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: F xisting new Half: existing new
Number of Bed roo
existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes 0 No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing O new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Namei'��-� ,L, �ai� n Telephone Number
Address :cz &Z��a�y S/, License#
Home Improvement Contractor#
Email i�'fd Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE _ DATE /S�/
L A
Bk 30483 Pg213 #23206
05-12-2017 @ 12 : 56p
�y
P�7
�md
Wpy
.don't
DEED RESTRICTION
WHEREAS,ALFRED L.BOUTIETTE,Trustee of the ALFRED D.
BOUTIET"TE TRUST u/d/t dated February 14,2012, established under the laws of the
Commonwealth of Massachusetts,being an unrecorded trust,see Trustee Certificate recorded in
Book 26132,Page 308,c/o 222 New Boston Road, Sturbridge, Massachusetts is the owner of
property located at 37 Wedgewood Drive,Centerville,Massachusetts(hereinafter referred to as
the"Property"),being more particularly described by deed recorded with the Barnstable County
Registry of Deeds at Book 26132, Page 310;
WHEREAS,Alfred L. Boutiette, Trustee of the Alfred D. Boutiette Trust as the owner
of said Property has agreed with the Town of Barnstable Board of Health to a restriction as to the
number of bedrooms which can be included in the home built on said Property;
U
WHEREAS,the Town of Barnstable Board of Health is requiring that the agreement for
q the restriction on the number of bedrooms in the house existing on the Property be put on record
o with the Barnstable County Registry of Deeds by recording this document;
3
m NOW THEREFORE,Alfred L. Boutiette,Trustee of the Alfred D. Boutiette Trust does
hereby place the following restrictions on his above-referenced Property in accordance with his
3 agreement with the Town of Barnstable Board of Health,which restriction shall run with the land
and be binding upon all successors in title:
l. 37 Wedgwood Drive,Centerville,Massachusetts may have constructed upon the
Property a house containing no more than four(4)bedrooms;
2. Alfred L. Boutiette,as Trustee agrees that this shall be a permanent deed
restriction affecting the property located at 37 Wedgewood Drive,Centerville,Massachusetts as
more fully described in the deed recorded in Book 26132,Page 310 and being shown as Lot 9 on
the plan recorded in Plan Book 243,Page 69.
For title of Alfred L. Boutiette,Trustee of the Alfred D.Boutiette Trust see the following Deed:
Book 26132,Page 310.
Client Fila/11455/0008/02384669.DOCX
Bk 30483 Pg214 #23206
EXECUTED as a sealed instrument this Vday of May,2017.
ALFRED D.BOUTIETTE TRUST
By:
Alfred.L. outiette,Truitee
COMMONWEALTH OF MASSACHUSETTS
Gyorc e sf�� , ss.
On this day of 2017 before me,the undersigned notary public,
personally appeared Alfred L. Bouti e,Trustee of the Alfred D.Boutiette Trust,proved to me
through satisfactory evidence of identification,which was❑photographic identification with
signature issued by a federal or state governmental agency,❑ oath or affirmation of a credible
witness,Z personal knowledge of the undersigned,to be the person whose name is signed on
the preceding or attached document,and acknowledged to me that he signed it voluntarily for its
stated purpose as Trustee of the Alfred D.Boutiette Trust.
otary ublic
My Commission Expires:
CARYN M. CR18TV
Notary Public
OMMO NAM OF MASBAV19E1Y8
MY Commmia" Expiry
No"MlMr 9, 2023
JOHN F. MEADE, REGISTER
ClientRIWI1455/0008/02384669.WCX BARNSTABLE COUNTY REGISTRY OF DEEDS
RECEIVED & RECORDED ELECTRONICALLY
Bk 30483 Pg215 #23207
05-12-2017 @ 12 : 56p
TRUSTEE'S CERTIFICATE
ALFRED L.BOUTIETTE,Trustee of the ALFRED D.BOUTIETTE TRUST u/d/t dated
February 14,2012 pursuant to a Trustee Certificate recorded in Book 26132,Page 308(the"Trust")
hereby certify that:
1. I,ALFRED L.BOUTIETTE,am the current Trustee of Trust;
2.The Trust is in force and effect and has not been amended or modified and has not been
revoked as of the date hereof,
3. The undersigned has the full power and authority to execute and record a deed restriction
with regard to the premises located at 37 Wedgewood Drive, Centerville,Massachusetts;and
4.There are no conditions precedent to the action of the Trustee which is,in any manner,
germane to the affairs of the Trust.
Executed as a sealed instrument under the pains and penalties of perjury this,L �! day of
May,2017.
ALFRED D.BOUTIETTE TRUST
By: /u
d L!Bo)Yette,Tniftee
LL THE COMMONWEALTH OF MASSACHUSETTS
�����
On this day of May, 2017, before me, the undersigned notary public, personally
appeared Alfred L. Boutiette proved to me through satisfactory evidence of identification, which was
❑ photographic identification with sign t e issued by a federal or state governmental agency,
oath or affirmation of a credible witness, personal knowledge of the undersigned,to be the person
whose name is signed on the preceding or attached document, in my presence, and who swore or
affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge
and belief as Trustee of Alfred D. Boutiette Trust.
NoVu]blic
CARYN M. CRISTY
Notary Pub11c -_
COIIMQNYYEA�IH Oi 11Agg�q
MY Commiseton &,Ml oa F. MEADE;�6N s! t
Client Filedl1455/0008/02388770.DOC November 9, 202$ BAR TABLE COUN79f-REGI STJtY•AF.UEEDS
-------EMVED & RECORDED ELECTRORICALLY
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use ly e tab 1. Inspector:
key too move your
cursor-do not Sean M Jones
use the return Name of Inspector
key. AUG 3 O,RECD
S M Jones Title V Septic Inspection
� Company NamePIU
74 Beldan Ln.
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/20/2010
Inspector's Signature Date
The system inspector shall s submit a of this inspection re vi yu t copy sport to the Approving Authority(Board
9 tY
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. q1A,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�y 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required.pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"f 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is Centerville Ma 02632 8/20/2010
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Cl ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•09108 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"( 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. CitylTown State Zip Code Date of Inspedion
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and.location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2008=46000 total= 126 gpd 2009=26000total=71 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 12/09
Date
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-0901 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r< 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owners Flame
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information: .
new s.a.s installed 2001
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gallons
Sludge depth:
3"
t5ins•09108 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
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
10"
How were dimensions determined? opened covers and took
measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
water level at bottom of outlet invert, outlet intact and in good condition. Tank not leaking and was
structurally sound.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
I r Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is Centerville Ma 02632 8/20/2010
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
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.):
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
44 Commonwealth of-Massachusetts
Title 5 official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owners Name
information is
required for every Centerville Ma 02632 8/20/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5 infiltrators
❑ 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.):
Stone and soil surrounding s.a.s was found to be dry by digging down to top and probing into it. No
evidence of past hydraulic overloading.Vegetation was normal.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owners Name
information is required for every Centerville Ma 02632 8/20/2010
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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A I 13
o I
❑0 2
o3
LS� s,
TA
11 1 . w3'
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t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner Owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-D9108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 37 Wedgewood Dr.
Property Address
Sonya Shapiro
Owner owner's Name
information is required for every Centerville Ma 02632 8/20/2010
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No. /�'�� ,l� Fee ;Z�)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPrication for Migogal *pgtem Construction permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Addre or Lot No. Owner's Name,Address and Tel.No.
:37 We6jeUjo01Dr- ce,,,�'eYvt�le�m�- ShA'P1rD
Asse or's Ma /P el SOS 4eag- P,()47
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
eal,s sroikcts Cp nsTr, Co
a3 rfX Ism IZ� Aims ►►"IlA
Type of Building: MW 1-7 4 1 HS- L el
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank !^O,� f)-.4 Type of S.A.S. 4
Description of Soil
A/ J
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i tied by this Board of Health.
Signe Date
Application Approved bx��. Date—�',; ;
Application Disapproved for the following reasons
Permit No. Date Issued
No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
_ es
PUBLIC HEALTH DIVISION+- TOWN OF BARNSTABLES MASSACHUSETTS
01ppYication for Migpont *pgtem Congtruction Permit
Application for a Permit to Construct( ,)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
re s r t o Owner's Name,Address and Tel.No.
r
►a le;srNrarr�,Ad�drres ann �N1o.�g t Designer's Name,Address and Tel.No.
1�6lly
+DU-T��ll��
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder�Vl
Other Type of Building No. of Persons Showers(, ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �`� '� Type of S.A.S:-�60V
i
Description of Soil
Nature of Re 'rs o lbe tin ( nswe 1pn applicab er/� 9-/v �� `ll A//
7-7A � � o jv �/ 7 v
Date last inspected:
Aireement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has_b_qrrissued by this. ealth.
Sign Date r
Application Approved Datt�` d 1
Application Disapproved for the following reasons
Permit N Date Issued s ��
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
ytif irate of (Compliance
THIS IS TO W- what tl�e..Can- ite Sewage Disposal System Constructed( )Repaired (� )Upgraded( )
Atari_ ( , }
at ��'' Gj/ Z;Voe� },gas been coas t _led in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ( dated Z 7 F O I
Installer Designer
The issuance f lsnOt sall not be construed as a guarantee that the Sys 11 fut}etiot�a design Inspecto
K ra
---------------------------------
T
No. ee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS
Migool *pgtem Congtruction Permit
Permission is herebyr ranted to Construct( )Repair( )Upgrade( )Abandon( )
System located at�i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: C gu4j;1ion must be completed within three years of the date permit.
Date: `'� � ' ��( Approve y'
� 4
116199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION NII
UCTION PERT
- --- (WITHOUT DESIC-1dTED PLANS
a
I, G,• �� ,hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 3 010 eG D/L(vulL _ meets all of the
following criteria:
This failed system is connected to a residential dwelling only. There are no commercial or business
/j uses associated with the dwelling.
j The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
i•, There are.no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
♦ There is no increase in flow and/or change in use proposed
'• There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum
adjusted groundwater table elevation.[Adjust the groundwater table using the Frimptor method when
applicable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the ro osed
P P
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) J�?' 3
B) G.W.Elevation a?0 +the MAX.High G.W.Adjustment.
DIFFERENCE BETWEEN A and B --
a
SIGNED: �= E DATE:
[Please Sketch proposed plan of system on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
T.twatth fotda:mn
f e '
. r
TOWN OF BARNSTABLE / v
LOCATION � ��,®�,,, D rw.e SEWAGE # FCDT- 31j v
VILLAGE CpN ,.. Lc, ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.&" 'TzwZS
SEPTIC TANK CAPACITY /000 IRIA4107v
LEACHING FACILITY:(type) Wi c—.0 y (size) f Z,7(�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERE--`i*6,
BUILDER R:6—W:�N—E
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
3�
A
-p3q ALA
Weller & Associates t/
Bayberry Square -- Suite 4C 2
1645 Falmouth Rd. -- P.O. Box 417
Centerville, MA 02632-0417
April, 18, 2001
Sonya Shapiro
37 Wedgewood Drive
Centerville, MA 02632
Re: 37 Wedgewood Dr., Centerville
Dear Ms. Shapiro
Please be advised that we have Hispected the existing sub-surface sewage disposal
system, namely the leaching facility. at the above referenced location. We found a 1000
gallon leach pit, with two feet (2') oFstone surrounding it. Therefore, the existing leach
pit has a leaching capability of 580 GPD, or sufficient capacity to handle five (5)
bedrooms.
If you have any questions; please do not hesitate to contact us.
Very truly yours. �ZH Of
O� DANIEL E. �y
p I BRAMAN t%
O CIVIL
1 ^
w .. No.�i2(8
William G. Weller o�f GJst�
ss�onAL ENS
4
Fax: (508)775-0754 Phone(508)775-0735
I THE COMMONWEALTH OF MASSACHUSETTS
.BOA R D F H E T H _
_..._.. .......O F...... :.. ........ .. ......'..
„e Appliratiun -fox Bt-spiuml Marks Tiltuitrixrtion Urruti$
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: rl-
fawner 17�.�. Ld�, .
Lcation-Address A r—
Installe Address
UType of Building �►�Nc h- Size Lot-._+�j"` �--___Sq. feet
Dwelling—No. of Bedrooms------ ---------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building <. No. of persons... _` Showers — Cafeteria
04 d Other fixtures .--9--� -•-- ---------------------------------------------
-----------
W Design Flow....................�o-___� -gllons per person per day.' Total daily flow--- -C ..•._----gallons.
WSeptic Tank�Liquid capacity _ __ allons Length................ Width................ Diameter................ Depth---._--_-.-----
x Disposal Trench—No_ _______________•.-_- Widtli..._......r-__. _ L ng � Ital leaching area....-.-._----__--_sq. ft.
Seepage Pit No_____ ____________ Diameter__ __ e nlet�'� g;al leaching ttre.-------------------sq. it.
{ ---------
Z Other Distribution box ( ) Dosing tank ( ) /'L2�t_ �
a Percolation Test Results Performed bY--_-------- ----------•--••-•---•------•-----•--------------•----------- Date---------------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..--__--_-___._.--.-----
L14 Test Pit No. 2----------------minutes per inch DeAtIest Pit.-______•----___-_- Depth to ground water_-.-____ _
-••--------- - ------ ---------------.....................•--..:............�-
--
Description of Soil-------------------------- -- ----• -----. --- �- �_.............. �
W
------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------..........................
U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
-------------------------------------------- .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 healt .
igned- '`—
Application Approved BY ----• --- { _...... --�...__----• -.. .
Date
Application Disapproved for the following reasons--------------------------------- -----------•-••------•------------••--• ......................................
------------------------------------------------------------------------•---------- _------------------------------------------------•----------------------------------------------
/ Date
PermitNo......................................................... Issued---�1 _1K------_-------_------
Date
No. ........... .... ................
THE,COMMONWEALTH OF MASSACHUSETTS
OARD 9F HE T
OF 65 ..
1,
orbs Tomitrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system t: T
- ------------ - --- ---- -------------------------------- ---•----- ....-------•-•- -------
or,- ---- --
If�t,on- e
/..3 1 f.'r- '-----.-- L I
._- __'_'_'_' .... Y _____'___ --------- p -
•kY�—s•—i.�
W dress
•• ••----- --•••--------•- -s.----------'-'-•-••-•-------•--••--•....._:_...-•-• ----------- - ------------ ••-- -----•- -- -----•----•---
" N _j*er Address a�
Type of�jBuilding Size Lot____ _______________________Sq. feet
Dwelling—No. of Bedroo Expansipii Attic ( ) -arbage Grinder ( )
aOther—Type of Buildin persons---------------------------- Showers ) — Cafeteria ( ).
d :Otl-fer fixtures ---------------------------------------------------------•------------------------- -------•-•---•-•---•••••-•---•-•------ •---------•-•---••-_
W Design FIX____________ .............................gallons per person per day. Total daily flow--------------------------------------------gallons.
W SejNiic Tank—Liquid cahacitv------------gallons
tength................ Width._._...__._.. Diameter---------------- Depth----------
xDisposal Trench—No-____'_______________ Width.................... Total Length-------------------- Total leaching arca........:'__._:.....sq. ft.
Seepage Pit No---------------------- Diameter.........._......... Depth below inlet.................... Total leaching area__.__-_,__._-._...sg. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation,Test Results Performed by......................_._._.______
a
a Pit No. 1_____________ i tes Per inch Depth of "Pest Pit.................... Depth to ground water_.___--.:.-_._.__.-----
--. ate----------------------------------------
Test
(Xq Test Pit No. 2________________miAtes per inch Depth of Test Pit------:............. Depth to ground water__-__.,_._ --_.-____-._.
-
Descriptionof Soil '•---------------------------•---=-----•-------------------------------------------=------•----------------------•---------_------------------------ -,
v
.. xV Nature of Repairs or Alterations—Answer when applicable. ______ __ !_______._______.______:________.___.-_. _'___
--------------------------•-------------------------._..- ----------- -
Agreerrtt: � ? f ,
The $undersigned agreesto Anst 11 the aforedescribK,,,Individual'Sewage,Disposal System in accordance with
ffthe provisigrts,oJ,, rticle XI of the St Sanitary Code,— The undersigned urther agrees not to place the',systeni in
toperatiori until a Certificate of Compliaiioe,•has be sstte-1 b -the •oard f
Application Approved By...... Pr r ' r' �, Af t ¢ •-+ru
E
AppllcaLi0,, s pproved for the following retzi. s.: Y'+. f
-K
r Date
,LL J
RY
_.___ ...... ra4�x� ti
Permit "" s ,
kt:
i � Y Date
THE COMMONWEALTH OF ASSAC)iU + r b.
Ca''w:k •v M1.'..
� ... g BOARD NE�� , ", '
4?. ..............0F...,.. ........ ...................
n r� x1rdifir fW rut li nrle 5<
TH T.0 E 1 atj the-In . wa Disposal r 1 1 d' Se geS�st -const ucted ( ) or Repaired` )
. � . bY --- - -
,.
has been installed in accordance with the provisions of Article X T State, Sanitary. Code s es' d 'in the
application forlisposal Works Cdnstruction'Permit No-____.___`••- b___. dated_t_ --- __ __ _.__
�' ...
THE ISSUANCE OF THIS CERTIFICATE,,SHALL'NOT.BE CONSTRUE® AS A GU RA TEE-THAT.-THE.
SYSTEM• WILL FUNCTION SATISFACTORY.
DATE -'-- Inspector_
-------------------------------
•»JA•w�41
THE COMMONWEALTH,dF"M"A SACHUSETTS
-�^ BOARD- F HEALTH
.:........ O F.... t
r NO. FEE ..............
�i > n gr (l Vtrurti rrutit
Permissioereby granted __- ----• ------ --------...........................................................
to Const`ru Repai ) an tidivjdual Sewage- p . '1 Syste
at No' g - -^° s "-
�• •- Street
•
as shown on the application'for Disposal Works Construction > ` No---
_. ted_ ..... 7�......
DATE.. ..... o q t•,. Board Health
f•
,
r
FORM 1255 HOBBs & WA, RI N• INC.. PUBLISHERS �j!
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