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Home My WebLink About0035 JUNIPER ROAD - Health 35 Juniper Ln. , Centerville A = 210 112 No. 4210113 ORA ESSELTE iox 0 0 0 0 x`'�, Commonwealth of Massachusetts a 10 ��a-- -- - I7 Title 5 Official Inspection Form � i111 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 35 JU_NIPER ROAD__ _ Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name —�— information is 2021 5/28/ required for every CENTERVILLE MA 02632--- —`-------_---.—__—.---_____.___ --.__-- --------__- _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 5 4r- PTLCTS on the computer, use only the tab Trevor Kellett key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return -- p------- ---------- —=------ --- -- ------- ------ — key. Company Name 350 Main St_------------------------- --- — „� Company Address WYarmouth — _ MA u_ 02673 City/Town — State Zip Code erica 508-775-2825 _ _ _ SI-13744 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails __ ____ 6/4/2021 _ Inspecto 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. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 18 | Commonwealth of Massachusetts � ��"��N �� Official U Inspection �� Title 0��N�� 8°N�/� . � u�� &—�NRn�~m��N Qxu�� X[ �� —. .. . . . . ��m��m m Form mmu Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 35 JUNIPER ROADProperty Address DAN|EL J ONE|LL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name .omnnauun is required w,�e� CENTERV�LE ______- MA 02632 5/28/2021 page. City/Town State Zip Code Date o,Inspection —' Inspection Summary |nuoaodon Summary: Complete 1, 2. 3. or 5 and all of and 6. 1\ System Passes: � Z | have not found any information which indicates that any of the,failure criteria described � in 310 CMR 15.303 or in 310 CIVIR 15.304 exist. Any failure criteria not evaluated are � indicated below. � Comments: SYSTEM IS IN WORKING CONDITION . � _ �� - 2) System Conditionally Passes: �l One or more system components 8Sdescribed in the "Conditional Pass" S8CUon need to be replaced or repaired. The syobem, 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 h3U0w|Og statements. If"not determined," please explain. The septic tank is metal and over 2U years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration 8raxfi|tr8tiUO Or tank failure is imminent. System will pass inspection if the existing tank is [ep|8CeU with 8 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 Certificate of Compliance indicating that the tank is |eaa than 20 years old is available. �� Y N ND (Explain below): Commonwealth of Massachusetts - IJ Title 5 Official Inspection Fore i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address D_A_NIEL J ONEILL IRREVOCABLE INCOME_ ONLY TRUST__ Owner Owner's Name information is CEN _ required for every TERVILLE MA 02632 5/28/2021 ------------_.---------...----.._.--------- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑- Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev 7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ys Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name information is CENTERVILLE MA 02632 5/28/2021 required for every ----------------------... --- ----------- - page. City/Town State Zip Code— Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For ,l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD__ Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name---------___--------------------- -- informa equiretionis CENTERVILLE MA 02632 5/28/2021 required for every -----......-_.._..--------..-...._----.-------_.--------- -.____-._.. -------.- —_-- -- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). 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:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �I'M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c� 35 JUNIPER ROAD Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name ---- ----- -- -- --- information is required for every CENTERVILLE MA 02632 5/28/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ 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)] t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 e. 'c, Commonwealth of Massachusetts Title 5 Official Inspection Form -� 1,I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD _— ..---- ------- --- ---- ----- — - -- Property Address DANIEL J ONEIL_L_IRREVOCABLE INCOME ONLY TRUST _ Owner Owner's Name information is CENTERVILLE MA 02632 5/28/2021 required for every _._._._—_ ________—_... — page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 _ Description: Number of current residents: VACANT-- 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 Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage '20 - GPD 119 - 9 ( Y 9 (9pd)) GPD _ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: SEASONAL Date t5insp.doc•rev 712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts y. Frill Title 5 Official Inspection For I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD _ Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner ---------__---___----------—___ Owner's Name information is CENTERVILLE MA 02632 5/28/2021 required for every —...__— 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 day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: - --- --- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: --- --- -- --- ----- Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: -- gallons How was quantity pumped determined? — ---- - - Reason for pumping: ---------- ---- ------------- t5inspAoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts f}m =T Title 5 Official Inspection Form 11! '�f i) Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 35 JUNIPER ROAD Property Address — ------ ---- ----- --- DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner - -- ------------------_.-.—.—....----- Owner's Name information is CENTERVILLE MA 02632 5/28/2021 required for every --._...-- -----...- -------- -- --- page. City/Town 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 systern owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 1997 PER BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): 2111 Depth below grade: Meet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): --------- — ---- — Distance from private water supply well or suction line: 1 01+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5. ®fficial Inspection Form "! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address — — DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST _ Owner ...------------------------------- --- Owner's Name information is required for every CENTERVILLE MA 02632 5/28/2021 _ _. _..-_.---_-- --...— -- -- -- ---- -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 1411 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: 1500 GALLON POLY — 1 , Sludge depth: ----._-------------. __—. Distance from top of sludge to bottom of outlet tee or baffle ------- Scum thickness ---- — -- Distance from top of scum to top of outlet tee or baffle --- --- Distance from bottom of scum to bottom of outlet tee or baffle — -- — -- How were dimensions determined? ESTIMATED—_ — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON POLY TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 14" BELOW GRADE t5lnsp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ... Ir 35 JUNIPER ROAD Property Address DANIEL J ONEILL_IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name information is CENTERVILLE _ _MA_ 02632 5/28/2021 required for every page. City/Town State Zip Code Date of Inspection D. System Wormation (cont.) 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora =� �.1) Subsurface Sewage Disposal System Form Not for Voluntary Assessments A _. r 35 JUNIPER ROAD _ Property Address — DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name --�— ----..�-- --- ---------� - information is CENTERVILLE MA 02632 5/28/2021 _ required for every --------------------------. --- -------- page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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 EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc.rev 7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts 1:= pry Title 5 Offlcoal inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name information is CENTERVILLE MA 02632 5/28/2021 _required for every _-�-----..._..-----_------------------------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: -- ® leaching chambers number: 4- INFILTRATORS ❑ leaching galleries number: ----- - -- ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: -- ❑ overflow cesspool number: -- ❑ innovative/alternative system Type/name of technology: --- ----- t51nsp doc-rev.70-612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts I, ,�I:• Title 5 Official Inspection Form ` "I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address DA_NIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name — ------- --- -- --- --- — --- information is CENTERVILLE MA 02632 5/28/2021 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.): 4 INFILTRATORS WITH T OF STONE FOUND DRY DURING INSPECTION 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 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For ", Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address _-._.._.._-------- ------ --- ------ ------ --- D_ANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name— —--- --- -------- -------- ---- - information isCENTERVILLE MA 02632 5/28/2021 required for every --------------___...__--------------..._--- ------ -.--------- - - — page City/Town State Zip Code Date of Inspection Cho System Information (coat.) 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ; Title 5 Official Inspection Form ,I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD Property Address D_ANIEL_J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner Owner's Name------ —'-- -- ---_ -_ —_ information is required for every CENTERVILLE MA 02632 5/28/2021 ... _ page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 _ 7r_ 1 :�j ,I at-rr' i t5insp doc•rev 7/26/2018 Title 5 Official Inspection Forin:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form --- i,,l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35 JUNIPER ROAD a -- ---- -- - - --- Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST Owner ----_----- --_ ----— ------------------- Owner's Name information is CENTER_VIL_L_E MA 02632 5/28/2021 required for every _._.__......_ .--- -_......-.-- ----------..._.-- -- --- _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet- — Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date - - ® 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: HAND AUGER PERORMED ONSITE AT TIME OF INSPECTION TO 10' ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp do •rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection t ,1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cX 35 JUNIPER ROAD Property Address DANIEL J ONEILL IRREVOCABLE INCOME ONLY TRUST _ Owner Owner's Na ------ -.._. ----..... -- ----- ------.._. - - - me -- information is CENTER. LLE MA 02632 5/28/2021 required for every _._._ ---_.-___---_ --------___--- ----------_--.-- _-- page. Cityl-rown 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 F t5insp doe-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL V WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works i construction permit signed by me dated , concerning the property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation ) +the MAX. High G.W.Adjustment DIFFERENCE BETWEEN A and B 0 � SIGNED : DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert TOWN OF BARNSTABLE !` SEWAGE # / 7 LOCATION y VILLAGE ASSESSOR'S MAP & LOT-a 6 - /!'L INSTALLER'S NAME&PHONE NC SEPTIC TANK CAPACITY a Tru �Tv 4 f LEACHING FACILITY: (type) _(size) S NO:OF BEDROOMS - BUILDER OR OWNER PERMTTDATE: — - 4-� --COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table�and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) .Furnished by ,��si �► _ 0 l r e- ,No. / '� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipp[ication for ;Di!5po!5a[ 6pelem Cougtructiou Permit Application for a Permit to Construct( )Repair(YO)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3'S'w"i Owner's Name,Address and Tel.No. Assessor's Map/Parcel G) Installer's Name,Address,and Tel..No. Designer's Name,Address and Tel.No. --ZA,. Jbe,A5 00 QA ✓� �� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -3-39 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank i75-OD Type of S.A.S. ' -` 1-Tv�`tct1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) �.Ik-GTA41 /j w r rL oIAI i Z v—e- D 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 a not 1p place the system in operation until a Certifi- cate of Compliance has been iss this Bo of Signed Date " �`1 7 Application Approved by t Date0 Application Disapproved for the following reasons Permit No. s' Date Issued ¢� No: � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE. MASSACHUSETTS m _ application for 33igpoal *pgtemc Construction Permit Application fora Permit to Construct( )Repair(Y"O)oUpgrade( )Abandon( ) ❑Complete System ❑Individual Components'" s Location Address or Lot No. 3 S�V r/`i pe,_\-4*-�Z, Owner's Name,Address and Tel`No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 8d 6,4 K-Te-4 481 Type.of Building: ' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(' ) r Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures } Design Flow J� gallons per day. Calculated daily flow 37P gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 757 0-0 Type of S.A.S. Description of Soil Akle _ S S Nature of Re airs or Alterations(Answer when applicable) 71W w _Y _ /fax -Ly► "�./CiL7rc to 62 S l t.Igf STGy`tf_ d r� Sr✓l S �`- /y�� 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 a not place the system in operation until a Certifi- cate of Compliance has been is his Bo d of Signed Date Application Approved by Date AO Application Disapproved for the following reasons Permit No. �' Date Issued �-"' '" ——-——————--————.—————————————'—, ———— ———— F-THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C'lT-Fy ab,the O - ' egvage Disposal System Constructed( )Repaired^(1<Upgraded ( ) Abandoned( )by t e r at cc--N 7 F`_y, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated Installer d e�`� Designer The issuance of this permit sha not be construed as a guarantee that the system.will',unction as designed. Date � / - Inspector r ----------------. ----J----------- - f - , No. —— Fee l%,' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mitpo5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) l System located at 3 J U Iy', ( !�! L I-f b I and as described in the`above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completedwithin three years of the date of thi/ it. Date: / �' �;J T Approved bys� 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 DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated — (� -�i , concerning the property located at 3-5- meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system 00 There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility J • There is no increase in flow and/or change in use proposed J • There are no variances requested or needed. SIGNED : DATE: ` 7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j xert yv .. 4i t\�O 1\\\ 1 �"QG Y- 4 'Y.^l V �'U�l i , �� l-� �- w TOWN OF BARNST ABLE q LOCATION SEWAGE# / 7 " y MLAGE ASSESSOR'S MAP & LOT.3.1 D - //Z INSTALLER'S NAME&PHONE N�Q� SEPTIC TANK CAPACITY I S V p d LEACHIlVG FACII.TTY: (type). LTv`' (size) S� • i NO.'OF BEDROOMS d • BLJ LDER OR OWNER PERMITDATE: �( —"J' - 9 COMPLIANCE DATE: /— -7-- 9 Separation Distance Between the: Ma�i�mum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Piivate.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 I 7r �OqqaK U�I3 1 'Town of Barnstable P# Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 °M Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: `LOCA'TYC)N& CENEttAV1VMATI(l�N Location Address Owner's Name Address Assessor's Map/Parcel: Engineer's Name NEW CONSTRUCTION REPAIR Telephone N Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft 3 SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) RECEIVED JAN 10 ��1997 HEAM D7 P.T. a TOWN OF CARN'37,:_;LE y1 � t fi "a. A- V' . 1 t 1 rr Parent material(geologic) Depth io Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION: 'C ti ASONa Method Used: Depth Observed standing in obs.hole: n. Depth to soil mottles: _- ,.r_h, ti,ao. in. Groundwater Adjustment ft. TOWN OF BARNSTABLE �� q LOCATION SEWAGE # / 7 VILLAGE C ASSESSOR'S MAP & LOT 6 - 1/'► INSTALLER'S NAME&PHONE N SEPTIC TANK CAPACITY 1 5 6-D o d -,C a6Ltz . +-tUc�Ty wT-�r('!� (size) LEACHING FACILITY: (type) �T � �( � ) ! NO.OF BEDROOMS BUILDER OR OWNER ^-1f�`z� PERMIT DATE: / - COMPLIANCE DATE:T— :7- 2 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 .--� -�o� `�01 fir" ��o� � �fir- � — l � D � � �a�� I:�,`�� " � ��!`��—