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HomeMy WebLinkAbout0011 WHITE OAK TRAIL - Health I 1 WHITE OAK TRAIL, CENTERVILLE A= III BE����EO J� �O Z UPC 12534 No, 2-� 1�-,..53;OR �ODo?•Go�`�p^ HA9TING8, MN / '?/- 0(00 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 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 fom�s A. Inspector Information on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key.. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code > 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjones6tle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 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 1217/2020 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.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 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 property located at 11 White Oak Tr Centerville is served by a Title V septic system consisting of a 1000 gallon septic tank and a 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 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.7126/2016 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 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma. 02632 12/7/2020 page. Cityfrown 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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.V2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts IFTitle 5 Official Inspection Form V Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Flame information is Centerville Ma 02632 12/7/2020 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subswface Sewage Disposal System-Page 5 of 18 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma 02632 12/7/2020 page. Cityrrown state Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t6insp.doc•rev.7PI6W8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail _ Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2.years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/262018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form kvow) - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma 02632 12/7/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per Y(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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 5insp.doc•rev.7M/2018 Title 5 Official Inspection Forth: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 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Flame informrequired is Centerville Ma 02632 12/7/2020 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 1000 gallon septic tank, 1000 gallon leach pit Approximate age of all components, date installed (if known)and source of information: original system installed 10-1-1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: fleet 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, vented through roof t5insp.doc•rev.7f262018 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's(dame information is required for every Centerville Ma 02632 12l7l2020 page. City(rown state Zip Code Date of Inspection D. System Information (coot.) 6. Septic Tank(locate on site plan): Depth below grade: 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 gallons 6„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. outlet cover is on a riser. t5insp.doc•rev.7/2812018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cost.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2W018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,r 11 White Oak Trail _ Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma 02632 12l7/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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_): t5insp.doc•rev.7/262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form—Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 required for every ..._ page. Cityfrown 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.): I *If pumps or alarms are not in working order, system is a conditional pass_ 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1x1000 gals ❑ leaching chambers number: — ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5'msp.Aoc•rev.7/2612018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 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.): Leach pit was video inspected from tank and found dry with a stain line approx. 9" below inlet invert. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal!System Form=Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma 02632 12/7/2020 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doe•rev.MW2018 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 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is Centerville Ma 02632 12/7/2020 required for every _______. page. 6 f own State Zip Code Date of Inspection D. System Information (cost.) 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 a«,, r? /,v3 C3 LP tfiinsp doc,rev.7/2612018 Idle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail _ Property Address Rafael Garcias Owner owner's Name information is required for every Centerville\ Ma 02632 12 I2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ fleet 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 was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 White Oak Trail Property Address Rafael Garcias Owner Owner's Name information is required for every Centerville Ma 02632 12/7/2020 . page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2; 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2rv7018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tea, 11 White Oak Trail v Property Address h>> Ana Mason Owner Owner's Name required for is every Centerville I/ required MA 02632 7/21/2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms :5"1 (8a's 0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return key. Name of Inspector Ford Septic Services, LLC ,ae Company Name P.O. Box 49 Company Address nA� Osterville MA 02655 Cityrrown State Zip Code 508=862-9400 S 12482 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 aluation by the Local Approving Authority 8/6/2018 Inspe t iS Signature Date The tem 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 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. ISins.doc•rev.6/16, Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 Commonwealth of Massachusetts • 11 Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form j' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. City/Town 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • Commonwealth of Massachusetts 1= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what Will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts p, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is Centerville MA 02632 7/21/2018 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or''no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins.doc•rev.6/16 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 a � 11 White Oak Trail v Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 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?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts p Title 5 Official Inspection Form 13, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 11 White Oak Trail Property Address Ana Mason Owner Owner's Name required for is every Centerville required for eve MA 02632 7/21/2018 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: unknown 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): 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form r; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is Centerville MA 02632 7/21/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed - 10/1/1976 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 22" 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 Dimensions: 1000 gal. Sludge depth: 2 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form = Il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 White Oak Trail `J Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. City(rown 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 23 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 15 How were dimensions determined? measure 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 Tees were present. The liquid level was even with the outlet invert.There was no sign of Ieakage.The tank is partialy under a cement pad. A riser was installed on the outlet cover. Grease Trap (locate on site plan): Depth below grade: N/a 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.doc•rev.6/16 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 I� 11 White Oak Trail u— Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. CityfFown 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: N/a 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form J, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 White Oak Trail u Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 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 n/a 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.): N/a * 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: l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � � 11 White Oak Trail V� Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 - 1000 gal. ❑ 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.): The pit was dry and clean. The scum line was approximatley 3' up from the bottom. A camera was used. There was no sign of failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/a 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IR Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is Centerville MA 02632 7/21/2018 required for every City/To wn State Zip Code Date of Inspection page. D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 3. Privy (locate on site plan): N/a Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form j1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is Centerville MA 02632 7/21/2018 required for every page. CitylTown 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 O � o a o � 3 3 � a86 gab a 30 aG C. 3 3y y l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 c. � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L � 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is required for every Centerville MA 02632 7/21/2018 . 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: 30 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: using topo and water contours maps ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I� I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 White Oak Trail Property Address Ana Mason Owner Owner's Name information is Centerville MA 02632 7/21/2018 required for every State Zip Code Date of Inspection page. City/Town 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 t t Comoro mea#th of Maswchusetts `Tit* 5 Official Inspection Form Subsurface SevMe`Diispwal Sysfem Form Not for Voluntary Assessments 11 Why Oaks Trail Property Address Laura Cheromcha 18 Cherry St Middleboro,MA 02346 Owner . (hers Name . ..Owner . MA 02632 11/22/13 P> . State Zip Code Date of Inspection ko must be Submitted on this form.kwqnctkm forms may not be altered in any way.Please see checklist at the end of the form. Man v�tetab Your t. Inspectflr cursor=dd.not :Jason.Burnie use ate return blame of Nebor#iood Waste Water nv 350 Main St IL Comer Address W.Ya MA 02673 CWr o" State ZipCode 508-775-2820 S5011 Teieptiorte kwber License Number B. Cerfift"on t c ►that I have:personally inspected the sewage_disposal system at this address and that the inf mmfion repoftd below is true,accurate and complete as of the time of the inspection.The inspection was pew based on my training and a rience in the proper function and maintenance of on site salvage disposal systems. I am a D9P approved system inspector pursuant to Section 1&344 of Me 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ (deeds Further Evaluation by the Local Approving Authority 1IM13 tnsp s 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. 10 sty ins au time of in$pection and.under corgis of use at ,. hen does not address jhcm rite system win perform in the future under same ordifilerent conditions of use. 1/13 =.9H3 Title 5 Of&+af hupec6on fartrc Substuface Sewage Disposal SysEarn•Page 1 of 17 v , 0011IM134140104M.Of f�trset s SttlbstwDftpo"- Form-Not for Voluntary Assessments 11 lA1tt#e-08M TrAd PirWwVAddfm Laura 18 Cherry St MWdlebomMA 02346 Owned O�irnef°s1r MA. 02632 11/22/13 e o>Mn state t*Code Date of tnspectron B. Ctrffw (cost.) tnspodboh Suer mary. Check A,B,C,D or E/always comps all of Section D A) . Pam: t have rice-found'any information-which indicates that any of the failure criteria described %ins 31Q-CtliR'%303 or in 310 CM 15.304 exist.Any failure criteria not evaluated are indicated>#�eloiiv. . Comfits: The system w.as found in good working ender at the time of inpsecho` n. The property has been vacant for sortre time. The inlet and outlet covers on the septic tank are 1'6"deep.There is no distribution box on this tyawn.The leach pit cover is'1'10"deep B) 'Syeftm OWWRIonaft Peres: one or more system components as described in the"Conditional Pass"section need to be repleeed.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 foik>wing 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 exfiitration 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 CeMbate of Comptiance`indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ft•3f13 Title 5 Official kapecbon Form:Subsurface Sewage Disp System•Pepe 2 of 17 COM61 i l bf MWwachusefts inspection. Form subsurface severe Dsposm System Form-Not for voluntary Assessments 1 t Whits Oaks Trail Property Address Laura Cheromcha 18 Cherry St Middieboro,MA 02346 Owner ownees Name Centerville AAA 02632 11/22/13 required for every p C own state Tip Code Date of inspection S.'Ce kw (cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) 'System Conditlonaily Passes(cost.): ❑ 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 N(with approval of Board of Health): ❑ broken pipes)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 wiN 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•3H3 Title 5 0MCW-1 kWactim Fomr.Subaaf m Sewage Disposal System'Page 3 of 17 commonweaft df Massachusetts usetis t o ft 1 f ss ct on Form Subsurface Dial System Form Not for Voluntary Assessments I I Wide Oaks Trail Property Address Laura:Cheromche 18 Cherry St Middleboro,MA 02346 owner Owner's!rams it i. ion is ,Cen�tllEe MA 02632 11l22/13 ri ti ed for every �yrr� stwe Zip Code Date of Irgm ion page:: B.-'Cell t: on (coat.) 2..System will fail unless the Board of:Health(arm Public Water Supplier,if any) Pip. iermines 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. rl 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 welt". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coiiform 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 to 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 ElDischarge 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 flaw t5 is•3M3 Title 5 Official tru peOw Form:Subsafaos Sewage Disposal System.Page 4 of 17 Cori°rm ► t of MbsSachusefts a IfISP64rbon Fonn Sabswftc* Dispasal System form-Not for Voluntary Assessments 11.Whiff E?aks Trail Laura Cheromcha 18 Cherry St Middleboro,MA 02346 Owner Owners Nafne infbffnation for awry MA 02632 11/22/13 requim,per. Cdylrown State Zip Code Date of Tr ion B. Ce r-ofrc 'ion (coat.) 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 pie if the well water analysis,performed at a DEP certified laboratory.,for fecal colifornm bacteria indicates absent and the presence Of ammonia n1troWn and nitrate nib,ogen 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 tha 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 11 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 systern 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 y13 Title 5 Official ht"chm Form:Subsurface Sewage D'-imai System-Page 5 of 17 .: . . COMMORWeafth 01"1i1sltit�s " ift ' 'nspection &*surface gam Disposal System Form-Not for Voluntary Assessments 11 White Oaks Trail > Laura Cheromdm 18 Cherry St MMdleb=,MA 02346 OwnEr Owne's Name infoffr9d1ion isreq Ceriteryitle MA 02632 11=13 P.ap. d for Y iTown State Zip Code Date of kopection C. C Check if the following have been done.You must indicate"yes'or'no'as to each of the following: Yes No M ❑ 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? 0 ❑ Has the system received normal flows in the previous two week period? ElHave Marge 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) 0 ❑ 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): unknown Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown t5iri8:3M3 Title 5 Official Mapectim Form:Subsurface Sewage Disposal System•Page 6 of 17 tftr8fiN 1 of h[1S ' '' i l ctioti Farm Subsuntee SswiraW SyMwn Form Not for Voluntary Assessments 1.t.White Daks Trail Laura Cheromcha 18 Cary St Middleboro,MA 02346 Owner, OwnWs Naine ma's Centerville 02632 11/22113 p° page. CWTown State .Tp Code . Date of Inspection D `*ys M lnfom"on Description: The system consists of a septic tan`lc'and leach pit There is no distribution box on this system. 0 . Number of current residents: Dries residence have a garbage grinder? ❑ Yes ® No is laut y on a sepwate swage system?'(include laundry system inspection ❑ Yes ® No information in'ffftreport) Laundry system inspected? Yes ❑ No seasonal use? ❑ Yes 0 No 11=Ogpd Water meter readings, if available(last 2 years usage(gpd)): 12=3gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy:occu Da years Y Date Cominemiainndustrtal Flow CondRions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(go) Basis of design flow(seats/pensons/sq.ft:, etc.): Grease#rap present? ❑ Yes ❑ No industrial waste holding tank present? ❑ Yes ❑ No ikon-santiary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: •3M3 rile 5 of W hVgCficn Fam:&&Rfffa0S Sewage Dim System Page 7 or 17 co�nrno�ll► � � Me fficiaf In.spectionform tub6wjjde sovigovispeaM System Form-Not for Voluntary Assessments f 1 Whft— Oaks Trail Property Address Laura Cheromcha 18 Cherry St Middleboro,MA 02346 Owner Owirers inforrnatio WMY n requir CenterviHe MA 02632 11/22/13 Pam.. moo+ State Tip code Date of tnd speon Q` S tnfarr Wh0n (tong) Last date of occupancy/use: Data Other Gibe below): General Information Pum{"g Rom: information: of Barnstable no pumping records Source ofWas system pumped as part of the inspection? ❑ Yes 0 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•W 3 Title 5 Mad Wspacbm Fa,rL subsLAace sewage Disposal System•Page 8 d 17 C011iltMOftlWOam t#- � ' 6n Form 5 !a # sct S6 bsWf ct Seia"e tUposat`Sy o Form-Not for Voluntary Assessments 11 White.Oaks Trail Prqmft Address Laura Chenomeha 18 Cherry St Middleboro,MA 02346 ots Name ir6mur m is MA 02632 11/22/13 �4u� Y CKyCe iHe state zip Code Date of inspection ASyStM I#t abort (cont.) Approximate age of all components, date installed(if known)and source of information: 1974 per prior report on file at the Bamstabie BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No BuiidhV S (locate on site plan): Depth1'11" 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.): We ran a sewer camera up the line and it was ok at the time of inspection. Septic Tank(locate on site plan): Inlet and outlet covers= 1'6" 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 Dimensions: 1000ga1 3" Sludge depth: t5ins-3M 3 Title 5 Official tropection Form:Subsurface Sewage Disposal System-Page 9 of 17 Ca t omainiachuseft T Official Insert-ion Form Subsurface gage posal 3yssWm faun-Not for Voluntary Assessments 1 i White Oaks Trail Property.Address Laura Cheromc ha 18 Cherry St Middleboro,MA 02346 owner Owners.Narne infornmation required for Centerville MA 02632 11/22/13 Pap- Cityrrown State Zip Code Date of inspection D. r fonn on (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 21+ 0" Scum thickness 4"+ Distance from top of scum to top of outlet tee or baffle 1'+ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tapemeasure 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 had both baffles in place and it was at a normal level. There were some roots growing in through:the cover on the outlet end and they were removed. 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•3M 3 Title 5 Official won Form:Subsurface Sewage Disposal System•Pap 10 of 17 , ram +� muse a i sped n FO SOWWtaci ftW-aOaWW System Form-Not for Voluntary Assessments 11 While Oaks Trall Pr"etfi►Address Laura Cheromcha t8 Cherry St Middleboro,MA 02346 Cromer Owner's Name for'is MA 02632 11/22/13 rd.qu�W for every C Centerville State Zip Code Date of Inspection Pam: D. system inform r#ion (cunt.) Comments(on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as reed to outlet invert,evidence of leakage, etc.): TWA or HokKft Tat*(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 Plow: 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 f5im•3/13 Title 5 offiaW kwecCw Form:sufumfaoe sewage Disposal System•Page 11 of 17 dm�bf Inspection Foy 5 "' System Form--Not for Voluntary Assessments 11.White 4 a Trail PmMrIyAftess Laura Chernrn'ja 18 Cherry St Middleboro,MA 02346 Owner Owner's Name ink" is MA 02632 11/22/13 regWrid for.every Centerville Staff Zip Code Date of Inspewon pa". Pityfr lwn D :System omation (cont.) D t*M Sm.(W present must be opened)(locate on site plan): Depth of Hquid level above outlet invert Co ents(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.): *'I"NO:DISTf IBUTION BOX**"" 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: The SAS was looted. 3N3 Title 5 Official Inspection Form:SdMgfaoe Sewage Disposal System•Page 12 of 17 M afftesachusetts 3 loffitWI Inspedion Fort Surface Sewap Dfiposal System Fonn-Not for Voluntary Assessments 11 White Oaks Trail Property address Laura Cheromcha 18 Cherry St Middleboro,MA 02346 owner ownees:Name inforsrn'� MA 02632 11/22/13 reguirk for every C ille state Zip Code Date of Ir>spedlon Pap D. i€tfon"altion (cone) Type: ® leaching pits number. 1-6x6 with stone ❑ leaching chambers number. ❑ leaching,galWieS number: ❑ wing trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovatre/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): The SAS was found to have no standing water in it at the time of inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5M 3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 C rimon of ch etts Tie Official Inspection form g `fit SystemFornr-Not for Voluntary Assessments 11 White Oaks Trail Property Addfm Laura Cheromcha 18 Cher 5t Mid W"ro,MA 02346 owner 6WVs Mama wftmaftn is MA 02632 111=13 required for every itCenterville state Zip Cock Date of Inspection . page. D. S"tem #�i mifflo t (coat.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(Date on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3113 Title 5 Of w Inspection Forth:Subsurface Sewage Disposal System'Page 14 of 17 C of Massachusetts 'f'r nSpctn Form Subsuftw Swag®D System Fon n-Not for Voluntary Assessments 11 White Oaks Trail Property dress Lava Cheromcha 18 Cherry St Middleboro,MA 02346 Owner, Owners Name hftn"afion is Ceatmille MA 02632 11/22/13 everyreqmod for CWTown State Zip Code Date of Inspection D. Sys d tl'at!On (cone.) 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 wafter supply enters the building. Check one of the boxes below: hand etch in the area below ❑ drawing attached separately 12,f#.Z o D D � A-C : a? " 9k'6 E • 3/ 6 aID'10 PC 16 t5ins•3H 3 Title 5 Of foal hspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Eom� f' a'Massachuwft TIt9 5 1OWWW In +ctio on n Subsualbce SiewiqleDispoW System Form-Not for Voluntary Assessments 11 White Oaks Trail Property Address Laura,Cheromcha 18 Cheny St Middlebor+o,MA 02346 Owner.. ownes.Name Centerville MA 02632 11/22/13 "Wred for every pap. City/sawn State Zip Code Date of Inspection D. 3y;stem Infa►r'rna#ion (cost.) Site Exam: Check Slope ® Surface water Check cellar Shallow wells Estimated depth'to high ground water. 16'per USGS Topo Maps 1974 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: SDW-252 Zone D water level 46.8 2.3x12=2'4"adjustment You must describe how you established the high ground water elevation: We referenced USGS Topo Maps dated 1974 and found the property is at Elev 50. Using the maps we found Wequaquet Lake is at Elev 34.This give you a proven seperation in elevations of 16'. From grade to bottom of the SAS you have a total depth of 7'10".This gives you a proven seperation of 87' from the bottom of the SAS to where groundwater is known to be. If you factor in the adjustment of 2'4"you now have a seperation of 5'10". Before Mth9 this Inspection Report,please see Report Completeness Checkitt on next page. t6ims•3H 3 Title 5 Official kspection Form:Stbsaufaoe Sewage Disposal System-Page 16 of 17 t COMMOWWWWOf Massachumft 5 Official inspection form gubsc ft" t 9ptern Form-Not for Voluntary Assessments I I While Oaks Trail. Lam Cheromd a 18 Cherry St Middleboro,MA 02346 owner owners t4ame kifortriation, - MA 02632 11/22/13 r��for every Centerville. State Zip Code Date of inspection per- E.Report ComplObiums Checklist 0 inspection Summary:A, B, C, D, or E checked 0 inspection Summary D(System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on:page 15 or attached in separate file t5ms-3M 3 Title 5 OftWhspedon Form:SuNufece Sewage Dispo System•Pap 17 of 17 i RECEIVED TROY WILLIAMS SEPTIC INSPECTIONS MAR 1 6 2001 Certified by MA Department of Environmental Protection TOWN OF BARNSIABLE (508) 385-1300 HEALTH DEPT. 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE, OFFICE, OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION / V 0 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 11 White Oak Trail Centerville,MA Owner's Name: Carol Alessi Owner's Addres).: 11 White Oak Trail Centerville,MA 02632 Dategof Inspection: October 30, 2000 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA OT660 Telephone Number: (508) 385-1300 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 systenv Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: I Date: /o 13e/oo The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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 paee I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I I White Oak Trail Property Address: Centerville,NIA Owner: Carol Alessi Date of Inspection: October 30, 2000 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: v// 1 have not found any information which indicates that anv of the failure criteria described in 310 CNIR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/19 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 indicatine 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30,2000 C. Further Evaluation is Required by the Board of Health: A114 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. I. 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 aseptic 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: 3 i Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 11 White Oak Trail Property Address: Centerville,MA Carol Alessi Owner: October 30, 2000 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or closeed 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 N� cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %,day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation. w1A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — �Al/o 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 coliforni 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 forma AM (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: N119 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(I.nterim Wellhead Protection Area—I WPA)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. 4 :Page 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspect►on: October 30, 2000 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No _ P--;;;ping information was provided by the owner. occupant, or Board of I iealth 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 ? _V1 _ 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 V1 _ Existing information. For example, a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 ,Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 White Oak Trail Centerville,1VIA Owner: Carol Alessi Date of inspection: October 30, 2000 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 62_ Number of bedrooms(actual): 02 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): cka o Number of current residents: -3 Does residence have a garbage grinder(yes or no): *o Is laundry on a separate sewage system (yes or no):Nu [if yes separate inspection required] Laundry system inspected(yes or no): A114 Seasonal use: (yes or no): .vo Water meter readings, if available(last 2 years usage(gpd)): 0/ -z 7.6ovT Sump pump(yes or no): Alo Last date of occupancy: z COMMERCIAL/INDUSTRIAL /V// Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basi4 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: r F Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Nu Pv� P A, — C Was system-pumped as part of the inspection(yes or no): .va If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, ibutie"ext,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: Were sewage odors detected when arriving at the site(yes or no): ivo 6 -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: I I White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 BUILDING SEWER(locate on site plan) Depth below grade: /6 4- Materials of construction:_cast iron /40 PVC /other(explain): V C— Distanc: fron-, private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): Ji +i SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ,concrete_metal_fiberglass_polyethylene —other(explain) If t*is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: S 'x 9 x <, /0 D 0 Sludge depth: Distance from top of sludge.to bottom of outlet tee or.baffle: 7" Scum thickness: Aloiyr_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: n/o 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.): P✓C, �c ?o✓ c� + f 14_ G n..c t.._ Go.h�.✓<.j- T'r ., �c+- w e r-c /�y...a/ i� Uo 6 r!�.-r. /UJ r✓i ul�-i. .` J f�G[..�c.o.g.� or- ck c",.. w�. �+•a,.i.-.t T., k. wa/S hod h hti� d � ,� p� n•—n� �t 41:s �ir►,t GREASE TRAP: (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.): 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: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 TIGHT or HOLDING TANK: N/ej (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 Flog+: 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: N /q (if present must be opened)(locate on site plan) 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.): ,Sn-k—A l ; n— +o fe.. h P,' PUMP CHAMBER: /u//*(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.): 8 ^Page 9ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I I White Oak Trail Centerville,MA Owner: Carol.Alessi Date of Inspection: October 30, 2000 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: r✓- 6 'X 6 'Le !, P; 5 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.):' L CESSPOOLS: <//,I (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: N1,9 (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 11 White Oak Trail Property Address: Centerville,MA Carol Alessi Owner: October 30, 2000 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 13��k )7 ' do 's'• /000 Y3 '� 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 . SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground tiater elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: 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: U S s You must describe how you established the high ground water elevation: cq.f �o r t(� ✓o ?� a /� u J r A o f /3 y k ' L, c ie �/ a -s G S Cj.2 r...� w - �/— 1'tn < O w 4 vim: �/ w �-e-� r J 6 v ✓ /f3 '. /�z l��n w. b l t c. L, i.., c,-� < f o ' G h 1 wQC N }-^ Ioc..g¢c -t r- 11 TROY WILLIAMS L - /6 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSE M'S 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 Propert% Address: 11 White Oak Trail Centerville,MA Owner's Namc: Carol Alessi Owner's Address: 11 White Oak Trail Centerville,MA 02632 � 43 Date of Inspection: October 30,2000 O ' Name of Inspector: Troy M. Williams v Company Name: Troy Williams Septic Inspections �� ��f� Mailing Address: " 19 Hummel Drive i �� Telephone Number: South Dennis,MA 02660 ION STATEMENT �o• e100, (508)385-1300 CERTIFICAT I certify that I have personally inspected the sewage disposal system at this address and that the infot'iomreported below is true,accurate and complete as of the time of the inspection. The inspection was performed b FdRon my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approN ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systenv Passes Conditionall\ I'as5es Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 5 2�Ja.�.., Date: to/3a loo The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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 Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ««""This report only describes conditions at the time of inspection and under the conditions of use at that time. i his 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 pace 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I i White Oak Trail Property Address: Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 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 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: /V�11 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l l White Oak Trail Centerville,MA Owner: Carol Alessi Date of frtspection: . October 30,2000 C. Further Evaluation is.Required by the Board of Health: A1119 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. _ 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 fron9 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 11 White Oak Trail Property Address: Centerville,MA Carol Alessi Owner: October 30, 2000 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or'clo22ed 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 N� cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. A//A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. A//o 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. _ A114 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.] Alb (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: N/19 To be considered a large system the system must serve a facility with a design now 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. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I I White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 Check if the following have been done.You must indicate"yes"or"no"as to each of the followine: Yes No _ 1 ;:;aping information was provided by the owner. occupant, or Board of I lealth 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? _V _ 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. 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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I I White Oak Trail Centerville,MA Owner: Carol Alessi Date of inspection: October 30,2000 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): cP Number of bedrooms(actual): 9 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 6k a o Number of current residents: _ Does residence have a garbage grinder(yes or no): Nu Is laundn on a separate sewage system (yes or no) ,vu [if yes separate inspection required) Laundry system inspected(yes or no): a/.q Seasonal use: (yes or no): .v0 Water meter readings, if available(last 2 years usage(gpd)): ,p—T i/�n r yd y6'i aauy A!10 h f Sump pump(yes or no): Aly Last date of occupancy: COMMERCIAL/INDUSTRIAL /V//9 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 Source of information: Nu A >c✓ ��7D �b_ by r.c U V✓•4✓. Was system pumped as pan of the inspection(yes or no): Nu If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM vl Septic tank,distributieR 699t, 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 aoe of all components. date installed(if known)and source of information: T s 4%.It-J 10/1 /76 nl,— as -6y.14 Were sewage odors detected when arriving at the site(yes or no): ,v0 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C SYSTEM INFORMATION(continued) Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30,2000 BUILDING SEWER(locate on site plan) Depth below grade: l� + Materials of construction:_cast iron _,/40 PVC /other(explain): / i 4 t c.�v f 4 V Distance from private water supply well or suction line: A//,I Comments(on condition of joints,venting,evidence of leakage,etc.): w e s w t i -Y+v J e..I e-v u.+ -1-h i 4i», u le n -L. {i o., . SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: 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: S 'x a-00" Sludge depth: S '. Distance from top of sludge to bottom of outlet tee or baffle: 02 7" Scum thickness: .yoivc Distance from top of scum to top of outlet tee or baffle: 1,'o.S 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.): P✓L Lt }_4 n Go.h( r.s.f=tom<<. r Ie w e rt �v J j`. �.Iu r 1-r, �y Q r-vi. r. At41 e✓i .�.�. J r� /GCl{� m OY ct w:,, c w �o'. -A. T ie wa S h o v�e e el u P v r,.v�f c { 44,', GREASE TRAP: 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30, 2000 TIGHT or HOLDING TANK: N/j (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 Flo% : 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:N/9 (if present must be opened)(locate on site plan) 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.): �/ /� t ,,J�'1(.. �t ut 1 i r�.� ^+'O f C.�c.. .• w: %l /'1 a �/_ 6y x 7'7>✓✓�.� Al. c/— O PUMP CHAMBER: /ul/a(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.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 White Oak Trail Centerville,MA Owner: Carol Alessi - Date of Inspection: October 30,2000 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 1— 6 'X 6 'Le t, tP i w•f1, . ,5' sfv��. 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.): ,• L t"c.L P:+' w c.s -Yt+/J,•+11.� �.�J"-� I,. o �„�/u.*.e t rat S c v� 1- 4y'I�- �<- 17 vr+t u�' r ns�•�,c,-/s`L M W i71 (+ ✓.�• �,t-$ 7�. / hr. / ' �t 1--b %fit NILf ;n vt ✓4- /V GJ de" J : 4 r u� r✓ry b(-ems», J %t'1 �,-� /J�+S ,- l..we rt -7 a..n�e r✓L S t H/ o��-- 1-i'— +i M� ca !C ,M J-�tL-4i G". CESSPOOLS: R1,j (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: N119 (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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 11 White Oak Trail Property Address: Centerville,MA Carol Alessi Owner: October 30, 2000 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. do,6,, { /WV �pIIOr S ' s�v„t. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I I White Oak Trail Centerville,MA Owner: Carol Alessi Date of Inspection: October 30,2000 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water /8 t'feet Please indicate(check)all methods used to determine the high ground Hater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: V S & s G•a,. s .•G�•_ M You must describe how you established the high ground water elevation: �6L—dl fA � cv �n C_f /o r c(� J r. /Z o F /3 U �'0 +-a✓ Tb•i H d i V S G/_S .-o..r..(J� w w ta.� hn .-,G r C I v .,4 a V a✓ 8*'�. w T TU 1+� 0/� G [ i1 Ya {.i.� S / do W G 11 OXe-7-AOM- 0 z LOCATION SEWAGE PERMIT NO. /e, "II e QA -- /ei4IL l9/-ow/0 VILLAGE (!?E,N7-rjz w*L L E fNSTA LLER'S NAME & ADDRESS l/�77�,R/�yo CPAs' .ysr.4,�cC B U K D E R OR OWNER DATE PERMIT ISSUED /0--/ � 7��_ DATE COMPLIANCE ISSUED 1o�a-a 9A a zreolc °TANK L eA cA44 ' I ...e o ac4 rr.4,0 e Ad No.OAZO.. .........7...... THE ccmmONWEALTH OF MASSACHUSETTS -"BOARD OF HEALTH .---------OF.......... - Applirtatiun -f>orr 4%ip ial Works C ongtrurtion Vamit Application is hereby'made for a Permit to Construct (v) or Repair ( ) an individual Sewage Disposal system ./ // /%........... -_-----_-_---_-------------- . � �, on-Address or Lot No. .... ••••. .................••••............................ 41 1/1 Owner Address ••• ----. .... - •• •!............................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms________ _____•.__..--..-_____---__---_-Expansion Attic ( ) Garbage Grinder pa, Other—Type of Building ---------------------------- No. of persons-.._____:_-.-_--__---___.__ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------ ------------------------------------ d W Design Flow................54....................gallons per person per day. Total daily Yow............2t ...................gallons. WSeptic Tank—Liquid capacity/0�gallons Length._�___6.. .. Width.4./6". Diameter_-5."S..... Depth............._. x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------f--------- Diameter------- °__..... Depth below inlet....6.`..__.._ Total leaching area-2'2-0..sq. ft. z Other Distribution box ( ) Dosing tank ( ) �� Percolation Test Results Performed by-------- - (-,..__ ' n.�____. _ _, Date----�.-_76-...___-_--- Test Pit No. 1..�__Z.__minutes per inch Depth of Test Pit...... ........ Depth to ground water--------"-_.___. fs, Test Pit No. 2................minutes per inch Depth of Test Pit------.------------- Depth to ground water------------------------ -----------------------------------------------------------------------x P _ ( �_ Y----4" - ai L 0 Description of Soil--____2. _�6._`.... ��� `� � ----- -- - ------------------------ U ------------ ----� �Y' - lU.i�t 5, -•---- ' ----•---------••--------------------------_-----•------------ W V 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued by the board of health: Signed- ----•- --- -----•---- - .......�-------- ----•--------------------------- APPlication Approved BY ✓ Date jam_..... ._ __. . . _ e Date Application Disapproved for the following reasons-------------------------------------------------------------------- ----------------------- ------------------- --•••-••••----•-•------••-••-•--•-----•----------•---- ------••••------•-•--•----••-•--•-•--•-••-•-•----•...---••-•-••--------- ------------------------------------------------------------------------- Date PermitNo..........................................--••---------- Issued................................--•---•--•--------•---• Date 07t No................. v.. ' FEs.. .......... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD /OF HEALTH y»/ J`i✓.__ .....OF..........!'. F'.'ti-..?' wet`- 'iM ................... Appliration -for 13isplaiittl Workii Towitrurtimn VPrutit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal Sys! * C/'11.4,ta� ci4l!� , G' c�j ion-Address ••----•--••--•-•-----------•----•'-------•or Lot No. ------ •--L lu/ 14---------------•--•------•-•----•------•--••--•• ----------•--•------•-•-----------•------------ Owner Address ay . . .. - ✓ ---------------------------------------- ----------------------- Install= er Address Q Type of Building Size Lot..-._----_----------------Sq. feet U Dwelling—No. of Bedrooms-------- --------.......................Expansion Attic ( ) Garbage Grinder QI Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures --------------------------------- W Design Flow_______________5Q-------_---_-.._-_.--gallons per person per day. Total daily flow............ -------------------gallons. 9 Septic Tank—Liquid capacity/040 gallons Length_- k.6". Widtli_ #JC).f_ Diameter__5_8..'... Depth................ xDisposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I.......... Diameter-------6l------- Depth below inlet....6_ ..._... Total leaching area-.2-70--sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by........G'"'f cCI r_ eft ?iI?` f�'..�. Date._..._.."..�6................... Test Pit No. 1_. ._ ___minutes per inch Depth of Test Pit------ ---___.. Depth to ground water. _"""""'`-._- ... rZq Test Pit No. 2................minutes per inch Depth ofirest Pit.................... Depth to ground water-----.--.------.---_---- -------------------- ----- -- .-_-•-- - --------------- ----- -- D Description of Soil----- g`" `� ��'" ` 6'!(,•+ x ----------------••--Z_y'!`-"I-� ---- ---------- ' -- - -------- -------- - -------------------------- --- w VNature of Repairs or Alterations—Answer when applicable.-...--------------------------------------------.---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the board of health. Signed ------• ..... ----•---- --------- Date - Application Approved BY 1 G�l�l�. ---D4-=----------- Application Disapproved for the following reasons----------------•----------------------•-------------..------•--------------------------•-------•------•-------- ..-------•-------•-----------------------------------------------•---•-----------------•-•-•-•--•-----------------.-----•-----------------------------------•--•--------------------- ---------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1..............OF......... ...................... Trrtif irate of 05umpliaurr T IS TO CE FY;-That the Individual Sewage Disposal System constructed or Repaired ( ) by62�1 r/ I ------------ n at----/1/`/-.1-l�----- -----------•-- C `k�t' • ll u has been installed in accordance with the provisions of Artie f The State Sanitary Code as described in the application for Disposal Works Construction Permit No--------------�� --------------- dated.-.._lU__--�....._�.��.........._._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ----------------------------------- Inspector----- . ............................... THE COMMONWEALTH OF MASSACHUSET S BOARD F HEALTH No. y'7� ......� _...........OF.... .. 1� n.. ..................... ........................... --••••---- FEE.. ............... Di va'sa I ork.i T tuitrurtion Permit Permission s ereby granted_-___ .oU Indi..__G�.J--_/�--------------------------- to Con or e r u Isposal' Syste - � ..at N ----------------•--------- - Street as shown on the application for Disposal Works Construction Perm' � -----------.-.-.-.-.-.-.-.-.-.-.- - tted �D-�- � •.. ...--•----vd of Health ' / 2 — DATE--`----(-�--•- ----------------•-- -•-------------------•------•-• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS y .. .�.....,,.a ,a..- , A 9 ��.\ .lk a, • _41 r - J ' i. _ ' -tit - •.A 4 0.r`- >- 4 , �,, . .`- { '\ t r 'yI L x a ,r,.. 1)){j{t " - 4 >l.'It - t .. 1' + ',i,` y.:.,.!�� `, /. y'[ y �'Y - fi a' ; , Y I 4 W.YJ. I 1 • a I. 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