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HomeMy WebLinkAbout0610 MAIN STREET (CENT.) - Health 610A MAIN STREET, CENTERVILLE A=207.013 o lIll ���D UPC 12534 No.2_153_R HASTINGS.MN Commonwealth of Massachusetts go - �3 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3> ,..�( 610 Main St Property Address , Phillips & Deborah Brown Owner Owner's Name information is /02632 M ill t enerve a 114/2017 required for every C � page. City/Town State Zip Code Date of Inspection W Inspection results mwlst be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information q on the computer, use only the tab- 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 1/14/2017 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 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: The dwelling located at 610 Main St Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon precast leaching chambers. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N . ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main St Property Address Phillips& Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main St Property Address Phillips& Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 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" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a� 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 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 I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I t5ins•3/13 Title 5Oficial inspection onFor m:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owners Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 8/7/98 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): 1.5 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown .State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" I Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be cleaned soon and again every 2 years for proper maintenance. Water level was even with outlet invert, tank was not leaking and was structurally sound. Outlet tee intact Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ` 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i i Tight or Holding Tank(tank must be pumped at tim e of Inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. Cityrrown 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.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts u u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �t 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): s.a.s. consists of 2 precast leaching chambers. Leaching facility was found to be dry with no signs of past hydraulic oveloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): (Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts a r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °y 610 Main St Property Address Phillips&Deborah Brown Owner Owner's Name information is Centerville Ma 02632 1/14/2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I ,�I ►3 c� 53 ❑ t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is required for every Centerville Ma 02632 1/14/2017 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 610 Main St Property Address Phillips & Deborah Brown Owner Owner's Name information is Centerville Ma 02632 1/14/2017 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f t ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, COPY use only the tab 1. Inspector: + key to move your (\ cursor-do not Troy Williams key the return Name of Inspector Y Troy Williams Septic Inspections Q Company Name 19 Hummel Drive Company Address iasm South Dennis MA 02660 City/Town State Zip Code (508) 385- 1300 S1682 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 r- LU C``J October 9, 2013 Insp or's Signature Date cci ci N Thetsystem inspector shall submit a copy of this inspection report to the Approving Authority(Board co of Haith or DEP)within 30 days of completing this inspection. If the system is a shared system or z c=' has a:-design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the 0 o repoj�jg the appropriate regional office of the DEP. The original should be sent to the system owner II— and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 OffiVn-: rface Sewage Disposal System-Page 1 of 17 f: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 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: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 1 J 4 t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i me 0 Utticial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville Property Address M-207 P- 13 Owner Phillips Brown information is Owner's Name required for every 167 Overlake Drive, Colchester VT 05446 page. City/Town October 9, 2013 State ZipCode e Date of Inspection B. Certif cation (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution bo x. S ass ins stem will p inspection if with a y ( 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 p ced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 -44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Ownees Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the.following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3113 Title 5 Mist Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owners Name information is required for every 167 Overlake Drive Colchester VT 05446 October 9, 2013 page. City/rown 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 N" Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M -207 P- 13 Property Address Phillips Brown Owner Owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system? Include laundry P 9 Y ( system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available Y 2 last ears usaged : 12=28,000 gals. ( 9P )) 11=25,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owners Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/ADate Other(describe below): NIA General Information Pumping Records: Source of information: Last pumped in 2012 per info from owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑. Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Cl Other(describe): t5ins-3113 Title 5 Official inspection form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank, d-box and leaching were installed on 8/7/98 per compliance Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18°+ feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Lines were found clear at the time of inspection. Septic Tank(locate on site plan): 23" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: i years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X10.5'X6' 1500 gallon Sludge depth: 411 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owners Name information is required for every 167 Overlake Drive Colchester VT 05446 October 9, 2013 C' /Town State Zip Code Date of Inspection page. �Y P Pe D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 21 8" Scum thickness none 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 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/ADate t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 f N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owners Name information is required for every 167 Overlake Drive Colchester VT 05446 October 9, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 11 oft 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is required for every 167 Overlake Drive Colchester VT 05446 October 9, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level 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.): D-box was found level and in working order. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is 167 Overlake Drive, Colchester VT 05446 October 9, 2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal. with4'of 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.): Soil was sandy. Chambers were found with very little water present with walls found clean with no staining. Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 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.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown k1pi Owner Owner's Name information is required for every 167 Overlake Drive, Colchester VT 05446 October 9, 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i I L � f . o 0 A- , 3 3 , 3z �3 � t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner owner's Name information is required for every 167 Overlake Drive Colchester VT 05446 October 9 2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 12.0'+ 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: MIW 29 Zone C 7.9' 2.9'adjustment I , You must describe how you established the high ground water elevation: Hand augered 5' below bottom of leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection was 2.9'. Bottom of leaching at 5.0'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 610 Main Street, Centerville M-207 P- 13 Property Address Phillips Brown Owner Owner's Name information is 167 Overtake Drive, Colchester VT 05446 October 9, 2013 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f 16-0" sr_ � �AIr F J�✓ Q610 wn 013 Living Room iage House 14'-6"x 15'-4° Main Street 24'0" i i Kitchen 9,_4 x 15'-4" 110 , 7T a7 770'-N UP 2 Car Garage 24'0" 24'0„ 23-4 x 23-10 s Y Stor. �a u•. 1� 24'6" roW EXISTING CONDITION FIRST FLOOR PLAN Note:All Dimensions are approximate and are not to be used for construction. t Brown Sleeping Area Carriage House 12-8 x 15-4 610 Main Street Centerville, MA 24'0" i Dressing Area 8'-1o"x 151-4" 7-7 N Bathroom Roof 7-4 x 9-2 Below _ 3,X5, Shower Lin. DN r 24'0" 24-0" Loft Storage 10'-0"x 11'-4" 11'-8"x 13'-4„ Roof'Below r 24'6" t EXISTING CONDITION SECOND FLOOR PLAN Note:All Dimensions are approximate and are not to be used for construction. 28'0" Cl. Bedroom #2 Bedroom #1 C1. 8'-2"x 12'-4" e 111-61 x12s-61 Lin. Bathroom Cl. 5I x 91 26'0" �DN a � i Living Room 13'-6"x 18'-6" Mud Room 8'-4" x 8'-10" 15 1 j r ■ Brown Cottage EXISTING CONDITION FLOOR PLAN 610 Main Street Note:All Dimensions are approximate Centerville, MA and are not to be used for construction. b �0 I i SO 1 p3 l ea �ZI47e 1/ 17-AeW-T- 63tta m e �l 7c;) 6� No. r Fee$ 5 O .0 O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �Dioogaf &p.5tem Con5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) XXComplete System ❑Individual Components Location Address or Lot No. 61 O A Main Street Owner's Name,Address and Tel.NoOy S ter R.E. Cenise v 1l e,Mass. 02632 420-1000 Assessors ap arce 610A MAin Street Centerville,Mass. Installer's Name,Address,and Tel.No.5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8-7 7 5-3 3 3 8 Box 66 Centerville,Mass. 02632 J.P.Macomber & Son Inc.-----`. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Type of Building: Dwelling XX No.of Bedrooms Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building RES No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 2 x 1 1 0=2 2 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 gallons Type of S.A.S. 2-500 gallon concrete Description of Soil T.n�y as nr� t�L er1 i t��arSP �a n chambers. 2 ' invert. Nature of Repairs or Alterations(Answer when applicable) Omitting two cesspools. Installing 1 -1500 gallon septic tank, 1 -Distribution box and two 500 gallon chambers packed in 4 of stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B ' d Hea . Signed Date 8 5 9 8 Application Approved b Date Application Disapproved for the fo owing asons Permit No. - Date Issued N. Fee$ 5 0.0 0 . I _ . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN'_0 F BARNSTABLES MASSACHUSETTS ZIpprtcation for Migogar *p!tem Congtruction Permit Application for a Permit to Construct( )Repair"( )Upgrade( )Abandon( ) XXComplete System ❑Individual Components Location Address or Lot No. 610A Main Street Owner's Name,Address and Tel.NoOyS ter R.E. a Centervil�e,Mass. 02632 420-1000 Assess &ra`pAle 13 610A MAin Street Centerville,Mass. Installer's Name,Address,tand Tel.No.5 O 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 Box 66 Centerville,Massd 02632 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass. 02632 Type of Building: 2, Dwelling XX No.of Bedrooms ) Lot Size ..___' sq. ft. Garbage Grinder(NO) Other Type of Building RES No.of Persons Showers( ) Cafeteria( ) Other Fixtures 'ir Design Flow 330 gallons per day. Calculated daily now 2 x 1 1 0=2 2 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1`500 gallons Type of S.A.S. 2-500 gallon concrete X Description of Soil -Loamy sand o medium coarsesand chambers. 2 ' invert. Nature of Repairs or Alterations(Ans"wer when applicable) Bmitting two cesspools. Installing 1 -1500 gallon septic tank,1 -Distribution box and two 500 gallon chambers packed in 4 of stone. 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- �ate of Compliance has been issued by this Bo d o'Hea . Signed 8/5/9 8 _..Date._ _:.. Application Approved by Application Disapproved for the fo wing Pasons --� Permit No. Date Issued _ ( ------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of QCompiiance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded(XX4 Abandoned( )by J.P.Macomber & Son Inc at 610A Matbn Street Centerville Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 5_11 dated Installer J.P.Macomber & Son Inc. Designer J.P.Macomber & Son Inc. The issuance of this pe it shall not be construed as a guarantee that the syste will �asdesid. Date q Inspector �. 0. AIV ---------------------- ----------------- No. aa I Feet 50.00 THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS i Mwioozar *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade*XX)Abandon( ) System located at 610A Main Street Centerville,Mass. 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 completed within three years of the date of this permit. Date: Approved by I 1 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) ], Joseph P Macomber Tr_ , hereby certify that the application for disposal works construction permit signed by me dated 8/5/98 , concerning the property located at 610A Main Street Centerville,Mass meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will 114.t be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) �lr r B)Observed Groundwater Table Elevation (according to Health Division well map) 30 c SIGNED • DATE: 8/598 ® �� LICE �SEPTICYSTEM INSTALLER I 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). 9 health folder:cent 4 I TOWN OF BARNSTABLE Q p� LOCATION 6, 10 A AU)i,.� 5� SEWAGE it /W - VELLAGE ri:E 02 ASSESSOR'S MAP & LOT 7"Di3 INSTALLER'S NAME&PHONE NO. 41:� c SEPTIC TANK CAPACITY 1 = LEACHING FACILITY: (type)JUQn y cis (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: F'6 —9 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 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 s 1 r © � � � �E� �� �� � (., \ �: �; � �� � x t s c� �'`� � � �� � ,� � G �� ��� 06-29-1998 02:58PM CENT OST FIREDEPT 5087902385 P.02. ' "Wvar tment retains original application and issues duplicate as Permit. APPLICATION and PERMIT .'for storage tank removal and transportation to approved tank disposal and in of M.G.Q. Chapibr 148, Section 38A, 527 CMA 9.00, application is hereby made b : Y accordance with the provisions • i � y Tank Owner Name(please print) Harold Geneen X Address 610A Main Street Centerville, MA stmor Stile �r Q Company Name ;Enviro—Safe Co. or Individual Address P•O.-OOX 810, E-Sandwich, MA �x Address Signature a yin r pe r,r� I Signature(if applying for permit) I r� ! IFCI Ce�lified. Other 0 IFCI Certified 0 LSP# Other Tank Location 6'10A Main Street Centerville, MA SFM Addross Tank Capacity(gallpns) (. O oey #2 0 i 1 Substance Last Sto Tank Dimensions(0ameter x length) Remarks: Firm transporting w te.. E nv i r O—Safe 329 MA State Lic.# _7 7_�_ Hazardous waste maoifestr MAK 140496 E.P,A. # MAD98526932-1 Approved tankdispoalyard Turner Salvage 002 Tank yard# Type of inert gas -Tank yard address 235 Commercial Street Lynn, MA CityorTown Centerville 01920 FDID# =PeDate of Issue June 23, 1998Dale of expiration Dlg safe approve(number. 9 8 2 0 0 5 9 8 4 i N Sate'QA Fite TO. Number-866-322-4844 SiynatQrp/Title of Office(granting permit {� After removal(s)send Form FP-290R slgnea by�oea�Fim Dept.to USS Regulatory mp4ance Uriit,Or`e Aahbuvaon Puce. Room 1310;Boston.MA 02108-161 S. . TOTAL P.02 i J TOWN OF BARNSTABLE r LOCATION 6, ja A PAM i;�> �� SEWAGE # C�' VDLLAG ASSESSOR'S MAP & LOT ?�y -7 INSTALLER'S NAME&PHONE NO. dM to c -waZ SEPTIC TANK CAPACITY 1 :!�I= C. ►A LEACHING FACILITY: (type)'Juns V�.y L.e ,As (size) i e A�s. NO.OF BEDROOMS -3 - BUILDER OR OWNER!, PERMITDATE: 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 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� X 6q r 0 o i ` �� 0 6� TOWN OF BARNSTABLE LOCATION IA1014SEWAGE # VILLAGE ASSESSO MAP & LOT °2�C/f Z/✓$�gGiP NAME&PHONE NO. ; ���o SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - c r.. - f�// � � 4 �3 r __. ��°� �� / . . i Y 1` r .�1 1� �� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA r ow am c ." vate 1112311s fad aUK "Our re j riq* tank, is over 30 Am L K"r�Jr�F^�,:�,��,.Y1r��, `,:���� �� Mul (" re4oi ed S���� A 03z*s £ seetta z 1 61 the OUR . t otic- 'N tlh$ 4•'16r�i- '"'• �k n+'W�iT � to ; ► � ` � j i F p( �g,� �. 7: �-..a .Y• �4.- a?.Y ,t�. q'y.3X `,-iC E 31 ., �y'F,, _etx kc •� � ft '' t Gy;, e ' t� ` 4� a� ��` :���y R 'wYl�-�� � � 1'- rtY �c� t¢v 3�t 7�yl. A4 'sdr 'r '.. sS`K' t '":s°^x9' ..� ,.. ,�"-P <� -',s'Y .a.:, 5 "G +HAY'} };' s t�. Z "`� ..:',m �.,.; .F r� y nr.�{:t# � � :� 4 Y sp r r* a'ww ..7yy' ! _. '��'/ '� nr. ,t1ZFfxs� - tit q. `y,J�.+ ''�.. '�•�' f {p.. _ } 1�4�� ^�y� J � '` :, it-.''' }. .. ° k } '„$ a ,e"..:_ •+i t�+• {}��/•'!� i° r,,. rif�Lu w.. `t a 7;� ..�s/ etawL,•, 1 !'1R- w di, .;NS G } �;4 '3',:.,ams L Y r ✓ Y� =$" * 3r WAMR" Vow VMS * .M� P VA _ Fad?/cFiit'1Mi.' RE.- Underground Yank. at 6JZ' MAIN ST a'CI 4 Our recoras indicate thot,:,Your unler round fuel (zA 61-31cast f storage t4nk is ov*r 30 y�ors aid. oral... r4qui `e by Section S. -Su sect on the Tour rota xa°' a# t Aegulat on rRe ordino Font and Cherli tat Storagt �5._ ��.y ua�a.�:, {. You are airected to relpove thi.� tank .sixty to d r your took is removed, pAaase fvrnish thi crffi:C4° Ov10 040 r is # r i ofter -1 t fcan Y Ur t ova t -f i � �r�ar fi•,. a��, � . wit'i n ninety (9-0) dAys of recofpt of the Ut You easy req e a a 4-earinq arovidcti 4 wr tt .rl# �aptit� (V' ui t'h rat v,e t day$�q for th i �Ordt-rr s�zetveda'/ � � � �.�.�� T. ri. 4 L N i «7M1 V I k..S.'K:�. t'F +d 4 .✓G 'i �' 1 !_ "_ I V- m Town of e4rnit btu Woatth Department y�LL(�.r.• (dfr yy y y� >p y� Yank a�f.p� � 2 ffAlk?,5� Sir •W W.'1+ W wfi Mi rl" :. `. • #f 8 1 �.....t ! -4 Our records inrAtcot + that, .youtr �x���� �� r� ���# �s � •�7'�r�`�`� aPAO #. � . t 4ardin4; f*jet d chea t Sr , S s e*art tj�,. +.aato of this .n€fiti +ire' F. t ti �'�'r«�.t0s t ,4 S / i reCef-ved by t4r oat-4 f .fit s � r�� r � r � � .. 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