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HomeMy WebLinkAbout0299 MAIN STREET (CENT.) - Health 299 MAIN STREET, CENTERVILLE A=208-113 UPC 2157CO 'R R HA8TIN08.UN aog-- �� a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 299 Main Street y Property Address Colvario Owner Owner's Name information is Centerville Ma 4/23/19 ' required for every page. City/Town State Zip Code Date of Inspection I.:+ ll 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. I fling out f When A. Inspector Information �'� r 3 fillip out forms on the computer, use only the tab Chad hathaway key to move your Name of Inspector . cursor-do not H PS use the return Company Name key. � V'R" Company Address . Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 4/23/19 Inspector's Signatur Date The system inspector shall mi copy of this inspection report to the Approving Authority(Board of Health or DEP)within d of completing this inspection. If the system has a design flow of 10,000 gpd or greater, t ' spector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. I Comments: Septic is in working condition. No failure critera encountered during inspection 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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 %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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . � 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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: sunknown 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 information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityfrown 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 1 ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no siigns of leaks or poor venting t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) 1500 gallon H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5'6" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place no decay or leaks visable pump tank every 2 years under normal usage. tank no required to be pumped during inspection. pump in 1 year under normal year round use. pump in 2 years for seasonal use t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 cam. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (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 j Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no carry overs no signs of present or past hydradulic failure. D63 h10 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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: no inspection port located. inspected throught Dbox and probed leakching area. soil was not saturated. no signs of hydraulic failure Type: ❑ leaching pits number: ® leaching chambers number: 6' infultrators 25 x12 x1.5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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.): no signs of wet soil or ponding present at time of inpsection 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form k�w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments n 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. Cityrrown 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 3 U � c O s \1) t I cc a1 �3 ' 1u9 ca t5insp.doc•rev.7l26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .• 299 Main Street Property Address Colvario Owner Owner's Name information is Centerville Ma 4/23/19 required for every page. CityrFown 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: 6'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 160 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 augered hole near leaching water 6' below surface. bottom of leaching 3.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 299 Main Street Property Address Colvario Owner Owner's Name information is required for every Centerville Ma 4/23/19 page. City(Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Cap Subsurface -b ace Sewage Disposal System Form Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is required for Centerville MA 02632 September 17, 2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key l(/ to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter,Inc. Company Name Q P.O. Box 371 Company Address Sandwich MA 02563 0 Cityrrown State Zip Code 508-88,8-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ' information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority September 28, 2010 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is required for Centervillep MA 02632 September 17 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon comple' n of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determin "(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 yea old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantia Infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank' replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ins ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the t k is less than 20 years old is available. ❑ Y ❑ N ND (Explain below): Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is September 17, 2010 Centerville MA 02632 Se required for p every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Healt ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or rep ced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pi ping more than 4 times a year due to broken or obstructed pipe(s). The system will pass insp tion if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by/heal , f Health: ❑ Conditions exist which require furthey the Board of Health in order to determine if the system is failing to protect public or the environment. 1. System will pass unless Boardtermines in accordance with 310 CMR 15.303(1)(b)that the system is noin 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 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17, 2010 required for P every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absor tion system (SAS)and the SAS is within 100 feet of a surface water supply or tribut ry to a surface water supply. ❑ The system has a septic tank and SAS a d the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SA and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an 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 nalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information isequired for Centerville MA 02632, September 17,2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes" "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit ' 400 feet of a surface drinking water supply ❑ ❑ the system is ithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system ' located in a nitrogen sensitive area(Interim Wellhead Protection Area—IW A)or a mapped Zone II of a public water supply well If you have answered"yes"to ny question in Section E the system is considered a significant threat, or answered"yes" in Section 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 2010 required for P every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 2010 required for P every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2008=233 GPD 2009=24646 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 09/12/10Date 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/s . ., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre ent? ❑ Yes ❑ No Non-sanitary waste discharge to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17, required for p 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No records found Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17, 2010 required for p every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: System installed 08/07/97.As-built and Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1110"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 11"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: 11'X 5'X 5' 1500 gallons Sludge depth: 6" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owners Name information is Centerville MA 02632 September 17 required for p , 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 911 How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Tank pumped and cleaned after inspection. Recommend pumping every 2-3 years. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ erglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top f outlet tee or baffle Distance from bottom of scum tb bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is required for CentervilleP MA 02632 September 17, 2010 every page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ElYes ElNo Alarm level: L 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 required for p , 2010 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two oulet. One has speed leveler in place. Equal flow. Very light solids carryover present. No sign of high water staining over outlet inverts. Pump Chamber(locate on site p/hamber, Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pumcondition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 2010 required for P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6-HC infiltrators w/stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers located and inspected with camera. Liquid level at base of chambers at time of inspection. No sign of past hydraulic failure. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 required for p , 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owners Name e uiredlon forls q Centerville MA 02632 September 17, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately S .r i pp 3 � 2 ti 1 J i Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t. 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is P required for Centerville MA 02632 September 17, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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. 1997 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole found no ground water to a level >5' below SAS (1997). Base of SAS 4' below grade. Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 Main Street Property Address Frank P. Colvario Owner Owner's Name information is Centerville MA 02632 September 17 2010 required for P every page. Cityfrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file J COMMONWEALTH OF MASSACHUSE'I'FS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A J CERTIFICATION Property Address: GCS '_t�i.A �e Owner's Name: 't QaT� Ct p . Owner's Address: ,7r`-1Ptl-}- s,`)L)e_ l I Date of Inspection: Name of Inspector:(please print) W i 11 i am E gbi nson Sr. O Company Name: William E. Robinson Septic Service Mailing Address: P O Box 10-89 Centerville, MA Telephone Number. ( 508 l 77 5-877 6 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 tooSS tiort 15.340 of Title 5(310 ChIR 15.000). The system: Passes Conditionally Passes Needs F Evaluation by the Local Approving Authority Inspector's Signature: Date: I ( a The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Neatth or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10 0U0 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of time DEP.The original should be sent to the system owner and copies sent to the buyer.if applicable,and the approXin ' ' authority. C r 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 • r , Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: aq'1nn', Owner. VCR i�p Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sysle asses: ]have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 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`bot determined"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether meta;or not)is structurally unsound,exhibits substantial infiltration or exfrltration 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 twbroken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 tines a year due to broken or obsWected pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is 1cmotred ND explain: ti Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � y \lE Owner: '� (P,_A1Y, C CA VC_�t C) Date of Inspection: t t I !i/ :2— 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 CNR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is.functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic.tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frortl 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. Wher: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. —Ck i T IICI C Date of Inspection: D. System Failure Criteria applicable to all.systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No// ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ �✓ D)'scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or flogged SAS or cesspool Static Iiquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or ,cesspool ,iquid depth in cesspool is less than 6"below invert or.available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ,6f times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. ny portion of cesspool or privy is within 100_feet of a surface water supply or tributary to a surface ter supply. _ g�Any y portion of a cesspool or privy is within a Zone 1 of a public well. 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 uatcr 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.] (YeslNo)The system fails. 1 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: d v l - 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: Glue 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 to a nitrogen sensitive area(lntcrtm wellhead Fro[cctton Area 1WPA}ora ma ppcd Zone I I of a public water supply well 1f you have answered"yes"to any question in Section E the system is comsidered a significant threat,or answered "yes"in Section D above the large system has fai'kd.The o%mcr or operator of arry large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 � Owner: Date of Inspection: ) �v Check if the following have been done.You trust indicate"yes"or"no"as to each of the following: Yes No __ ✓/Pumping information was provided by the owner,occupant,or Board of health V/ Were any of the system components pumped out in the previous two weeks? /Have Has the system received normal flows in the previous two week period? 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?(1f 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? _T Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b7was or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 7 the facili owner and occu ants if different from ownerprovidedw' facility ( p ) tth 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 77- Determined Existing information.For example,a plan at the Board of Health. _ in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CUR 15.302(3)(b)J 5 f Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �Clq V�G_i f1% ' , `{' Owner• Cu"-1 (, ' i 0. Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: a Does residence have a garbage grinder(yes or no): is laundry on a separate sewage system(yes or no):n [if yes separate inspection required) Laundry system inspected(yes or no):r. Seasonal use:(yes or no).1W Water meter readings,if available(last 2 years usage(gpd)): 000(O Sump pump(yes or no): a-00CD_ -- i © t C)GO Last date of occupancy. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _ gpd Basis of design flow(seaWpersons/sgfl,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: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: `" Qallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM %Z tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _lnnovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner ) y ) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)'V`d 6 I'af c 7 of I I OFFICIAL INSPECTION F0101—NOT FOR VOLUN"CARY ASSL•'SSNIEN I's SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C nn � SYSTM INI�OI ALATION(continued) Property Addrtss:avl� t- ,�—k; C \n • 41eet Dalt of Insptcllon: At J/ aoa'j BUILDING SEIVER(Iucatc nit site plan) Depth below gradc: / Mattrials of construction:_cast iron ✓_40 PVC_other(explain). Distance from private stater supply well ur suction lint:_ Conuncnts(oil condition of juints,venting,Evidence of Icakabc,ttt.): y SEPTIC TANK:"'/"(locatc on silt past) Dcpth below gradc: ic- Material of eonstrucliun:,—/cuncrcle metal fiberglass pulyetlsylene _uUicr(txplain) 1f ni h is racial list age:_ is age cunfinncJ try a Certificate of certificate) Compliance(ycs or nu):—(attach a copy ul Dimensions: i SbD (0- f/a—j Sludge dcpllc g r' _ Distance from top of sludge to bullum of uullcl tce of bafllc: ` Scwn thickness: / " Distance (ton►top of scum to 1up of uuUet lce or bafllc: fir, Distantc fiom bunuut of stunt to butauin of uutl tcc or ba(tle: I low score dimensions determined: 6Qc'E+t r s 4n- _ Cununcnts(oil pumping rccummuidatiuns,inicl and oulicl tcc or Ca fllc condition,structural intcbrity,liquid Icvcla Cas,.,elaled to outlet utvert,evidence of�eakage,etc-): ---� .--�L.. I.Gf— � .� •�•C• i�i"f' e a n K .�.P;'�" d c. n - e� C te-n� art S11C) J-t�'it,",y GREASETKAP� eatc un site plan) Depth below gradc:_ lrlalerial of"risiNctiun:_euucrcle—inetal fiberglass_pul)-etitylene _other (caplaul): — Dimcnsions. Scum 11iick»css: Distance from fop of Scwn to 101)of outlet ice or bafllc:_ Distantc Gonl bollunl of scuiu to bullum of outlet ice or bafllc: Dale of last pumping: Cununcnts(oil pumping iccomnicridaliurls,inlet and outlet ice ut bafllc condilira,stiuctuial intcbrity,liquid Icvch as related to oullcl int•ul,uidclicc of leakage,cic.): 7 )'age 8 of I I OI"I-ICIA,L 1NS1'EC-1'ION I;OI(111—N07' I;Oit VOLUNTAltl' ASSL•'SSWNTS SUBSUI ACl1 SLWACI: DISPOSAL SYSI*LNI INSI'EC"PION POI(NI 1'Al(T C y� J'I�EA1 INI�OI AIATION icontillucd) Property Address: -Aq `t.r) Owner: Dale of lospcclloo: TIGHT or 110LDING TANK:A/Mlarde inust be pumped al tilne of iaspection)(lucale on site plan) Depth below glade: Material of construction:,__concrele_alctal_fiberglass_�)Ulyctbylcrle otlicl(cxplain): Uinlcnsions: Capacity allulls Design flow; gallunslday Alarm present(),cs or no): Alarm level: Alann in wulkili order Date of last pumping: 6 (yes or nv): Cununcnts(condition of alarm and float switches,cic.): DISTRIBUTION DO\:Zif I)rescru must be opencd)(locate oil site plarr) Depth of liquid level above uutict im•crl:_0 r` Conune (note if box is level and Jistribw leakage into or out of Lux,etc.): lullto Outlets equal,oil)-evidence of sulids calt)•u%.cr,any CvidetlCC of j3nt j �t�t! GtZv( w t-Qtic� nn PUAIP CRAINI11L11 N( (locate vn site plan) Punips in sl•uiking order(yes or nu):_ Alanns in%corking order(yes or no):__ Con►rlicnls(llule condition of pump chautbcr,"ll)dlliurl Of pllnips and ahpUrtCllanCCS,etc.): Page 9 of i l OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �n SYSTEM INFORMATION(continued) Property Address: �ci HcOp -�1� ee-A Owner: CR_ 0 Date of Inspection: i) SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching 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.): jf:4 - 1->>^ L,-1,Q fz.+rwv - >✓� S.4,� v �►y,l r�,i�c , 1.c CESSPOOLS'I'(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY V hA(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tA S -e Owner: li74�D Date of Inspection: .7 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. a F?N p_V4 6 !3_1� fib,, 10 Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• Xicl VW,-) eFi1,- Owner. 1 VGt f D Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water .5�kfeet 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 4i e-54-Z&wcA 64 4ccrsf,4 `Z�-�•+ ,)� i�c✓��s b(� 11 Town of Barnstable OF 1HE Tp� Regulatory Services saxivsrnsz a Thomas F. Geiler,Director �$ •0� Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this.Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE �/ LOCATION ti SEWAGE # / (.) VILLAGE ASSESSOR'S MAP& LOT C1d 1- 10 INSTALLER NAME&PHONE N0. 2 7 — S 1 7 L SEPTIC.TANK CAPACITY LEACHING FACILITY: (type) /yam (size) S ! f NO*­OF BEDROOMS 3 BUILDER OR OWNER V PERMITDATE: (f� C — �? 7 COMPLIANCE DATE: "�1 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 oti 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 �b 6 +Y No. Fee $5 0 .0 0 THE COMMONWEALT OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatton for Migomt *pttem Conetructton Vermtt Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 299 Main Street Owner's Name,Address and Tel.No. 61 7—2 4 2—3 3 3 2 Assessor'sMap/Parcel Centerville, MA Frank Colvario 299 Main St, Centerville, 02632 Installer's Name,Address,and Tel.No. 775-8776 Designer's Name,Address and Tel.No. Vim E Robinson Sr, Septic Sery PO Box 1089 Centerville MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( nO 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) Title 5 Septic installation consisting of 1500g tank, D—box, and 6 stonepacked infiltrators. 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 thiA lealth. `n Signed Date Application Approved by Datee 15:0-5 Application Disapproved for the following reasons Permit No. " Date Issued -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Colvario BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( x )Upgraded( ) Abandoned( )by at 299 Main Street Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated -~ r Installer WM E Robinson Sr Sept Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector N Fee $5 0.0 0 o. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLICHEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(X Upgrade( ,Abandon( ) El Complete System ❑Individual Components ,F Location Address or Lot No. 299 Main Street t Owner's Name,Address and Tel.No. 61 7—2 4 2—3 3 3 2 \ Oenterville, MA I. Frank Colvario Assessor'sMap/P�cel 9/ if 299 Main St, Centerville, 02632 - Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 `` Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sery PO Box 1089, Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( np Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r 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 offR irs orAlte i s(Apswe when a licable) Title 5 Septic installation •,consis ng of �50 g �an�C, D�'ox, and b stonepacKed intiltrators. 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 issue by�it ar f Health. Signed Date G• Application Approved by Dat Application Disapproved for the following reasons ` ~ d Permit No. a. Date Issued --------------------------------------- THE COMMONWEALTH.OF MASSACHUSETTS., Colvario BARNSTABLE, MASSACHUSETTS S (Certificate of Compliance T�` THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(k, )Repaired ( X ) Upgraded( ) Abandoned( )by at 299 Main Street, Centerville as been cons ted i accor ance with the rovisions of T'tl 5 and the for Di s osa1 S stem Construction Permit No. "'~ �� dated ' . Installer p WM E Robinson Sr Slept ySry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector `s 7"�/ --------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS Colvario PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogal *pgtem Congtructton Permit Permission is hereby grge9d to CTis Street �p ( X)Upgrade( )Abandon( ) System located at Centerville, MA Installer: Wm E Robinson Sr Septic Service 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:Consgvction,,�nust,be,completed within three years of the date of t Date: Approved b TOWN OF ram;i LOCATION: . _VILLAGE: v ffw/ #: '10g — ( �3 PERMIT#: _ I NAME:IN PHONE#: SOsps _LEACHING FACILITY: (type)�rA� '�,,��, � sized 07,��L at l-°vJ x 1,5-b MO.OF BEDROOMS: BUILDER OR OWNER: }� �,,�,,�\� Co�Li%�C-\ PERMIT DATE: _ COMPLIANCE DATE: DRAW DIAGRAM ON BACK 1 r:vim. W41� 1 a tD orf` 6 � I Li TOWN OF BARNSTABLE LOCATION 11114 '' 6. 1 SEWAGE # VILLAGE f" f ASSESSOR'S MAP & LOT CJQ I INSTALLER'S NAME&PHONE NO. l S SEPTIC TANK CAPACITY /3' LEACHING FACILITY: (type) � (size) ;�L S—� NO. OF BEDROOMS 3 BUILDER OR OWNER G Q Z V A i2 t .6 PERMIT DATE: COMPLIANCE DATE: 57_ 9 r 9 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 1 I . � L� � �� � � -��...i a---., t � i �� x �_ �' '� I ~'I 13 i � �l ,1 �, f ' f �® �- t `�� ��� �� �-' e a .� NOTICE: This form is to be used for the repair of failed septic systems only CERTIFICATION OF SKETCH AND APPL ICATION FOR A DISPOSAL FORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) V I,William E. Robinson,Sr.,hereby certify that the application for disposal works construction permit signed by me dated y-- 41:�"2 117 , concerning the property located at 299 Main Street, Osterville, YU_meets all of the following criteria: * here are no wetlands within 300 feet of the proposed septic system. * 'here are no private wells within 150 feet of the proposed septic system. 'the obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. There is no increase in flow and/or change in use proposed. *-'i'here are no variances requested or needed. SIGNED: 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 proposes a certification plot plan,this plan should be submitted). r; 6 1� "' 1 i �f J S 1 a 1 1F / � 't l `/ Y s v \ V J