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HomeMy WebLinkAbout0008 WOODVALE LANE - Health 8 Woodvale Lane Centerville P Mon A = 190 186 I I 'II�f �QECYC(FO UPC 12543 No.5_ 3LOR 'O�"OST.CONSJ��� HASTINGS.mu COMMONWEALTH OF MASSAC r /HUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m C DEPARTMENT OF ENVIRONMENTAL PROTECTION David B.Mason,R.S,Certified Title V Inspector,508-833-2177j�� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Owner's Address:Jones c/o Deutsche Bank Nat'l Trust,1761 E.St.Andrews Place,Santa Ana,CA F Date of Inspection: May 28,2008 M'l Name of Inspector: (please print)David B.Mason rr , Company Name: N.A. Mailing Address:4 Glacier Path East Sandwich,MA 02537 ' Telephone Number: 508-833-2177 . coco '3 CERTIFICATION STATEMENT �rr I certify that I have personally inspected the sewage disposal system at this address and that the info ation reported t below is true,accurate and complete as of the time of the inspection.The inspection was performed aced 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 15340 of Title 5(310 CMR 15.000). The system: X Passes _Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatu -'7 Date: The system inspector shall submit a copy of this inspection report to the Approving uthority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System as inspected is operational. Increase in occupancy may result in failure. The information as identified represents only the condition of the system on September 20,2008 at 11 AM and does not represent a warranty on the future operation of the system. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 3 of 11 PART A CERTIFICATION (continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 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: OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I _ Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. a Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up ? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site. _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 (per assessors records)Number of bedrooms(actual): 3 septic design DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): (330 gpd capacity) Number of current residents:_0 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2007;143,000 2006; 111,000 Sump pump(yes or no):No Last date of occupancy: Current COMMERCIAL/INDUSTRIAL 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: Board of Health Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Pumped for maintenance;May 1998 and April 2004. TYPE OF SYSTEM _X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 Were sewage odors detected when arriving at the site(yes or no):no OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 7 of 11 PART C SYSTEM INFORMATION (continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 BUILDING SEWER(locate on site plan) Depth below grade: Approximate;24 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 12 inches Material of construction: X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 11" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness: 10 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues. CI Cover to grade on inlet. Riser on outlet which is 8"below grade. GREASE TRAP: N.A. 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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -?,I. 1 T.. . .. - III I^^l 7 Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 TIGHT or HOLDING TANK:—N.A.—(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X (if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert: liquid level even with outlet pipe 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.): In good condition,no evidence of solid carry-over,effluent level with outlet pipes. Box is 16 inches below grade. PUMP CHAMBER:_(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.): OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 SOIL ABSORPTION SYSTEM(SAS):—X_(locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number —X_leaching chambers,number: 2 500 gallon chambers _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, etch No ponding over the system,no excessive vegetation over the system. 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: _N.A._(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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Page 10 of 1 I PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 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. W REAR A ]3 0 0 O Al 26" 131 24' 0 A2 16'-6" 132 35' A3 23' 133 49' i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r:a c T.....- r..— 411 1Z11nnn 10 Page 11 of 11 PART C SYSTEM INFORMATION (continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_33_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography. Used Town of Barnstable Groundwater Contour Map. f \ COMMONWEALTH OF MASSACHUSETTS z E EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u r n d DEPARTMENT OF ENVIRONMENTAL PROTECTION F 5�0v David B.Mason,R.S,Certified Title V Inspector,508-833-2177 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Owner's Address:Jones c/o Deutsche Bank Nat'l Trust,1761 E.St.Andrews Place,Santa Ana,CA Date of Inspection: September 20,2008 Name of Inspector: (please print)David B.Mason Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _Conditionally Passes — Needs Further Evaluation by the Local Approving Authority Fails 6 Inspector's Signatur ate: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System as inspected is operational. Increase in occupancy may result in failure. The information as identified represents only the condition of the system on September 20,2008 at 11 AM and does not represent a warranty on the future operation of the system. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced (THIS IS REQUIRED TO BE COMPLETED) 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: OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' Titles rs Tnenartinn Fnrm 6/1i/1000 2 Page 3 of 11 PART A CERTIFICATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 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: OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Titles r%TnQnPoflnn Fnr An VNI01) 3 Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the.system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Titles r%Tnenartinn Pnrm All 1gM000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up ? X _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS, located on site. _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X _ Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. Titles S Tnenartinn Rnrm A/1 C/7000 5 Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 (per assessors records)Number of bedrooms(actual): 3 septic design DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity) Number of current residents:_0 Does residence have a garbage grinder(yes or no):NO(Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]Per owner Laundry system inspected(yes or no):NA Seasonal use: (yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 2007;143,000 2006; 111,000 Sump pump(yes or no):No Last date of occupancy: Current COMMERCIAL/INDUSTRIAL 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: Board of Health Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Pumped for maintenance;May 1998 and April 2004. TYPE OF SYSTEM _X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1999 Were sewage odors detected when arriving at the site(yes or no):no OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL S L SYSTEM INSPECTION FORM Titles 5 Tnenartinn Fnrm An si')nnn 6 Page 7 of 11 PART C SYSTEM INFORMATION (continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 BUILDING SEWER(locate on site plan) Depth below grade: Approximate;24 Inches Materials of construction:_cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident leakage. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 12 inches Material of construction: X_concrete_metal_fiberglass_polyethylene_other(explain)_ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1000 gallon tank Sludge depth: 11" Distance from top of sludge to bottom of outlet tee or baffle: 14" Scum thickness: 10 inches Distance from top of scum to top of outlet tee or baffle: 15" Distance from bottom of scum to bottom of outlet tee or baffle: 12.5" How were dimensions determined: Actual measurements with tape and scour stick. Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues. CI Cover to grade on inlet. Riser on outlet which is 8"below grade. GREASE TRAP:—N.A. 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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Tit1a 5 Tnenartinn Fnrm A/1 S/)f)00 7 Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 TIGHT or HOLDING TANK:_N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working'order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X_(if present must be opened)(locate on site plan) Depth of liquid level even with outlet invert: liquid level even with outlet pipe 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.): In good condition,no evidence of solid carry-over,effluent level with outlet pipes. Box is 16 inches below grade. PUMP CHAMBER:_(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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title G Tncnanfinn Fnrm F1151100n 8 Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number _X_leaching chambers,number: 2 500 gallon chambers _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, etch No ponding over the system,no excessive vegetation over the system. 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(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.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T41P S TnenPrtinn Fnrm A/1 r%nnnn 9 Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 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. W REAR A B u 00 0 ^ Al 26" B 1 24' A2 16'-6" B2 35' %P-1 A3 23' B3 49' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Titles 5 Tncnar4inn Fnrm 1;/1 S/')(1M 10 4 Page 11 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane,Centerville,MA Owner's:Jones Date of Inspection: September 20,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_33_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography. Used Town of Barnstable Groundwater Contour Map. Titles G Tnenartinn Fnrm A/1';i9nnn 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL-PROTECTION 1" TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F,OXZM � PART A CERTIFICATION PARCEL , Property Address: 8 Woodvale Lane - Centerville, MA Owner's Name: Gerard Lettieri RECEIVE D Owner's Address: Date of Inspection: o 1 MAY 14 2004. Name of Inspector.(please print) W' 1 1 i am E- •Robinson Sr. - TOWN OF B Ar%;,.. -E Company Name: William E. Robinson Septic "Service HEALTHHP'i. Mailing Address: P O Box 1089 Centerville, MA Telephone Number:- (5081 775-8776" 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 SS ton 15340 of Title 5(310 CMR 15.000). The system: . Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �i ��G ,�- Date: `T The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh. yr 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 seat to the system owner and copies:sent to the.buyer,if applicable,and the approxing authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 Woodvale Lane Centerville, MA Owner. Gerard Lettieri Date of Inspection;. f Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys[ Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System Conditionally Passes: One or more system components as described in the"Conditional Pass,"section need to be replaced or rep " ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.' Ans r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exist" g tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ling that the tank is less than 20 years oid is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or o strutted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with ap roval of Board of Health): broken pipe(i)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstriucted pipe(s).The system will pas inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is TCmovod s , explain: Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 Woodvale Lane Centerville, MA Owner: Gerard Lettieri Date of Inspection:/- C. Further Evaluation is Required by the Board of Health: f onditions exist which require further evaluation by the Board of Health in order to determine if the system is fail''tn to protect public health,safety or the environment. 1. ystem will pass unless Board of Health determines in accordance with.310 CMR,15,303(1)(b)that the s stem 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. S ten will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s rface 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 fronl 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 Gee 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 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). . , Property Address: 8 Woodvale Lane Centerville, MA - Owner: Gerard Lettieri Date of Inspection: A„�5e D. System Failure Criteria applicable to all systems: You Aust indicate`yes".or"no"to each of the following for all inspections: Yes o _ 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`surfaee 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 le"ss'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 I OO.feet of a surface water supply or tributary to a surface water supply. Any portion of.a cesspool or.4privy is within a Zone I of a.public well. _. Any portion of a cesspool or privy is within SO 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 wafer supply well with no acceptable water quality analysis.]This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/NO)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To a considered a large system the system must serve a facility xvith"a design flow of 10,000 gpd to 15,000. gPd - Yo must indicate either"ycs"or"no"to each of the following: (Th following criteria apply to large systems in addition to die criteria above PP Y g Y yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet ofa 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 I you have answered"yes"to any question in Section E the system is ransidered a significant threat,or answered 'yes"in Section D above the large system has faikd.The owner ar operator of any large system considered a igniGcant threat under Section E or fatted 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Woodvale Lane Centerville, MA Owner: Gerard Lettieri Date of Inspection: 4C�q— Check if the following have been done.You must indicate`)es"or"no"as to each of the following: Yes No/ _ .Pumping information was provided by the owner,occupant,or Board of Health LZWcre 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? 7/ 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: Yes . no _ = xisting 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 aPP roximation of distance . is unacceptable)13 10 CMR 15.302(3)(b)) 5 Page 6 of 11 ' OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 8 Woodvale Lane en ervi e, MA Owner: Gerard Lettieri. Date of Inspection: — FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) J Number of bedrooms(actual) DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):— [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_ Water meter readings,if available last 2 ears usage d 2003 - 4 6,0 0'0 g � ( Y S (gP ))� Sump pump(yes or no):._ — 0 0 Last date of occupancy: COMMERC LMiDUSTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): ipd Basis of design ow(seats/persons/sgft,etc:): Grease trap pre ent(yes or no):_ Industrial wast holding tank present(yes or no):— Non-sanitary ste discharged to the Title 5 system(yes or no): Water meter r dings,if available: Last date of o'cupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system_pumped as part of the inspection(yes or no):4jz( If yes,volume pumped:A,,:,o allow- How was quantity umped d termined? Reason for`pumping. , Ty OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all co m onents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): � 6 L Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_C SYSTEM INFORMATION(continued)' Property Address: 8 Woodvale Lane Centerville, MA Owner: Gerard Lettieri Date of Inspection:_AX �. BUILDING SEAVER(locate on site plan) Depth below grad Materials of cons ction:_cast iron 40 PVC____other(explain): Distance from pr vate water supply well,or suction line: Comments(on ndition of joutts,'venting,evidence of leakage;etc.): SEPTIC TANK: 1 1 ca e`(o ton site plan) Depth below grade: t Material of construction:_concrete metal fiberglass_polyethylene _other(explain) _ If tank is metal list age:— Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ri: . Dimensions: L L Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: L L/ Scum thickness:-- --- Distance from .top of scum to top of outlet tee or.bafile. Distance from bottom of scum to bottom of outlet tee or baffle: 49 How were dimensions determined:_ CT 7L�� G Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): l � GREASE TRAP: (locate on site plan) Depth below grade: Material of constructio :_concrete metal fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of sc in top of outlet tee or baffle: Distance from bottom o scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on puntpin recommendations,inlet and outlet tee or battle condition,structural integrity,liquid levels as related to outlet inv ,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: 8 Woodvale Lane Centerville, MA Owner: Gerard T.E?tti Pri Date of Inspection: ' TIGHT or OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below ade: Material of co struction: concrete metal fiberglass Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present res or no): Alarm level: Alarm in working order(yes or no): Date of last puF : Comments(con of alarm and float switches,.etc.): DISTRIBUTION BOX: r 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.): { PUMP CHAMBE (locate on site plan) Pumps in working orde (yes or no): Alarms in working ord r(yes or no): Comments(note Bond' ion of pump chamber,condition of pumps and appurtenances,etc.): 8: Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Woodvale Lane Centerville, MA Owner: Gerard Lettieri Date of Inspection: _ - SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type 1 aching pits,number._ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cessp of must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet ii vert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater infl w.(yes or no): Comments(note condition ofi oil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site Ian) Materials of construction: Dimensions: Depth of solids: Comments(note condition f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10'017 11 OFFICIAL INSPECTION-FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 8 Woodvale Lane Centerville, MA Owner: Gerard Lettieri 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. ,rlC o � I 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: 8 Woodvale Lane Centerville, MA Owner. Gerard Lettieri Date..of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells <G� Estimated depth to ground water Z feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: eked with local excavators,installers-(attach documentation) ccessedUSGS database-explain: You must describe how you established the high ground water elevation: S m pZ 11 No. 9� �s Fee $5 0 L THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Mitpont *pgtem Com5truction Permit Application fora Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. * Wood.vale Lane , Centerville , MA Jerry Lettieri Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm E . Robinson Septic Service P 0 Box 1089, Centerville , MA Type o Bu' ding: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) New Title -5 D-box and 2 stonepacked. ZeR��'1 r`�c`lI11�1PrS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of Health. Signe O 9 Date Application Approved by Date Application Disapproved for the following reasons \ Permit No. Y Vr Date Issued No. ' 9� / _ .. Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �YT PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for Oizpaal *pgtem Construction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System Mndividdal Components Location Address or Lot No. Owner's Name,Address and Tel.No. uM Woodvale Lane, Centerville, MA Jerry Lettieri Assessor's Map/Pazcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm E. Robinson Septic Service P 0 Box 1089, Centerville, MA r S- ` Type of Bu' ding: Dwelling No.of Bedrooms 3 4 Lot Size — sq.ft. Garbage Grinder( ) Other Type of Building No. YP rs`o�`� s 7 Showers( ) Cafeteria( ) .t Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type;rof S.A.S. Description of Soil Sand _:_ . Nature of Repairs or Alterations(Answer when applicable) New T ltle -5�,D—box and. 2 stonepaeked 1 earh �h,amt�Pr� Date last inspected: Agreement: ; The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 4n accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of Health. " ✓ C�. Signe © Q Date I/JAYApplication Approved by Date Application Disapproved for the ollowing reasons Permit No. t, 9 l Date Issued --'-------------- ------ THE COMMONWEALTH OF MASSACHUSE Lettieri BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Aband ned b Wm. E. Robinson Septic Service at WOo3va a Lane , Centerville ha constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '' dated Installer Wm E . Robinson Sr. Designer vr,.., 7 The issuance of this pe sh"11 not`�bernstrued as a guarantee that the s s- 1 will function tinny/as denec)' � yr�' �r Date /� 0 t Inspector / 7, !�,/ X XV — — ✓ —— " ------------------------ -- Fee�W THE COMMONWEALTH OF MASSACHUSETTS Lettieri PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1Wi!5po!5al bpgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 8 Woodvale Lane , Centerville and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. D Provided:Constructio st be ompleted within three years of the date of t ' ermit. Date: ,�... Approved by ifll i ? llsl 'f .• r _ TOWN OF BARNSTABLE LOCATION® /Q® o�^�'`y� � � SEWAGE# '' � �o/_ VILLAGE ASSESSOR'S MAP&LOT '"` O& INSTALLER'S NAME&PHONE NO._ K6 :2 Id—2 2 4 SEPTIC TANK CAPACITY /L$ � LEACHING FACEL=: (type), (size) �m NO.OF BEDROOMS �y BUILDER OR OWNER PERMIT DATE: .S`/ _COMPLIANCE DATE: 2 _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . 1 /7 �� 1oP� ��e� :._� �� � r �. �grf �� �� ��� � �� NOTICE: This Form Is To Be Used For The Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works .construction permit signed by me dated r-/ concerning the property located at 8 Woodvale Lane, Centerville, MA meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. ` * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) S0. 6 B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED:-1,. ` DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). • m 61jq d ti R6.�4 go r TOWN OF BARNSTABLE i LOCATION /i�a v...�yk ! � SEWAGE # VILLAGE ASSESSOR'S MAP&LOTJJLfjb& INSTALLER'S NAME&PHONE NO. '7 i, SEPTIC TANK CAPACITY I&D-6 LEACHING FACILITY: (type)r2 (size) 1 .S-;2- NO. OF BEDROOMS 3 M BUILDER OR OWNER PERMIT DATE: S'/% 2 4m/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by V / ,00%. I