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Home My WebLink About0050 PHEASANT WAY UNIT #A - Health (2) SOB Pheasant Way Fmrly; 63 pheasant Way Centerville A=227 - 142 #'s 61 & 63 combined Slip o4 OCYQO�'�a llll UPC 12534 No.2-153LOR HASTINGS. MN a 1 0 u O r LOCL.TIO'N 1 SEWO,C,E PERMIT UO. IN ST LER 5 U,&t Al ADDRESS —LAID 13U,1 DER 5 ' .Q WMF— ADDRE SS ..........4r .......... 6 v A41 DLATE ' PERt-A T 155UED D ATE COMPLI b t�ICE ISSUED ; �( r h a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 't 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 ; Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:When , filling out forms A. Inspector Information 5l,v ILI--�qa on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main Company Q Company Addrdr ess W Yarmouth MA 02673 City/Town State Zip Code . 508-775-2825 SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 8/10/2020 Inspector's Signah a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc rev.712612018 Intle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form �t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 IS IN WORKING CONDITION 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): 15insp.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 $I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u %F' 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 or 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a <� �e Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments !% 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is CENTERVILLE MA 02632 7/31/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a'septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS,is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form M1 i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information Is required for every CENTERVILLE MA , 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA, Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form ls, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 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.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 6 of 18 Commonwealth of Massachusetts -- � Title 5 Official Inspection Form I . p i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: SEASONAL 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): '19- 128 GPD '18-117 GPD Detail: ONE WATER METER FOR PROPERTY PER COMM WATER Sump pump? ❑ Yes ® No Last date of occupancy: SEASONAL Date 15insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts - Titie 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 50B PHEASANT WAY V Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day tgpdi 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: 10/24/2016 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Yea Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�� 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution'box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from 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: 25+ ESTIMATED Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3211feet 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.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED i5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name Information is required for every CENTERVILLE re wired for eve MA 02632 7/31/2020 � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 22"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y [I 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: 1n Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i Commonwealth of Massachusetts �A Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , ! 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Y� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !%f' 50B PHEASANT WAY V Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town 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 EVEN Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT l5inap.doc-rev.7126/2018 Title 6 Official Inspection Form:Subsurface sewage Disposal System•Page 12 of 18 aSe, Commonwealth of Massachusetts ,p Title 5 Official Inspection Form ' h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . !% 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): PUMPS AND ALARM IN WORKING CONDITION * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6X8 PIT ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc rev.7/26/2018 Title 6 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 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is required for every CENTERVILLE MA 0263,2 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6X8 PIT WITH STONE FOUND DRY DURING INSPECTION WITH MINIMAL STAINING AT 3' 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 Inspecuon Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information is y _CENTERVILLE required for ever MA 02632 7/31/2020 page. City/Town 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.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts IF Title 5 Official Inspection Form 111 Sewage Disposal System Form-Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 3499.4 Owner Owner's Name information is _CENTERVILLE re uired for every MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•page 16 of 16 , Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name required for is y CENTERVILLE required for ever MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +15, feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER TO 15'WITH NO WATER ENCOUNTERED Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc-rev 7/26/2018 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts -,, Title 5 Official Inspection Form i5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50B PHEASANT WAY Property Address CHRIS BULLOCK-253 SE WELLS DR STUART FL 34994 Owner Owner's Name information td for is re wired for every CENTERVILLE MA 02632 7/31/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form Inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 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 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 •� r \ i� ti � � .+� • 1 a • . � ' i �! ` 1. _ .,..._ _, .__ _._. .. _� %_— r I .. � ' t Commonwealth of Massachusetts ao?7-/)�- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A Pheasant Way,Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. 4�kb owner Owner's Name aA 07 'r information is Stuart �0,1/� �I�W FL 34994 10242016 required for every Cityrrown State Zip Code Date of Inspection t\7 Pap- Mn Inspection results must be submitted on this form.Inspection forms may not be altered in ad?. way.Please see completeness checklist at the end of the form. I foM A. General Information S1# /X0 5 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key Cape Cod Septic Services & 1 Company Name 350 Main St Az Company Address a W.Yarmouth MA 02673 Citylrown State Zkp Code 508-775-2825 S15016 Telephone Number Ucense Nuffdw B. Certification I certify that 1 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 6 10/312016 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 shaved 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 W 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 thattime.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•W 3 Title 5 offidal tqp OM Form&tagfeoe Sewage Disposal System•Pap 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. 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 exMtration 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 r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is Stuart FL 34994 10/24/2016 required for every page. Citylrown 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 Forth:Subsurface Sewage Disposal System•Page 3 of 17 I t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way Centerville MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owners Name information is Stuart FL 34994 10/24/2016 required for every 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 '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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- 1 0,000g pd. ❑ ® 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 1 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 page. Cityrrown 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? ® El available 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): 110x3= i 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. City/Town 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)): 2014=59gpd 2015=82gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 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 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 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 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): t5ins•3/13 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 50A Pheasant Way, Centerville MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is Stuart FL 34994 10/24/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20+Est. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer locate on site plan): 3211 Depth below grade: 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.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 22" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500Gal Dimensions: 3-4" Sludge depth: 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 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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 Scum thickness lit Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. Concrete baffles in place are solid. Tank at normal operating level. Inlet cover 22" below grade with outlet 6" below grade. I a Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): i Dimensions: Scum thickness i 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 Four:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y�. 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 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: 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is Stuart FL 34994 10/24/2016 required for every 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 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and solid with minimal solids carryover. No sign of overloading or hydraulic failure. 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.): 1000Gal Pump chamber in good condition. Chamber is clean *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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ; ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): i j 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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.): I j { t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 it r Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50A Pheasant Way, Centerville MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owners Name information is Stuart FL 34994 10/24/2016 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 t5ins•3/13 Title 5 Official Inspection Form: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 rr 50A Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is Stuart FL 34994 10/24/2016 required for 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: 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: 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 50A Pheasant Way Centerville MA 02632 Property Address Chris Bullock 253 SE wells Dr. Owner Owner's Name information is Stuart FL 34994 10/24/2016 required for every page. Cityrrown 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 � r , > s f F r r s r r i r QQAi } A f 1 � r H GN r F f / J 'ft ) { l 5 f 5 1 Y a t' S f , J A J t r J , f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50B Pheasant Way,Centerville, MA 02632 4 Property Address p Chris Bullock 253 SE Wells Dr. .46 Owner Owner's Name 9 irft CM required for � Stuart &4160 lAel FL 34994 10/24/2016 � required.for every per, Cityrrown State Zip Code Date of Inspection fV Inspection results must be submitted on this form.Inspection A nspection forms may not be a16er�n any way.Please see completeness checklist at the end of the form. Importurt filrmg out forms A. General Information zQo(o on the computer, use O*the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of fropector key. Cape Cod Septic Services Q Company Name 350 Main St A At Company Address W.Yarmouth MA 02673 Cityy(rown State Zip Code 508-775-2825 S15016 TeWtone 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 dispos'al systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CUR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/31/2016 Inspectoes nature 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. is report only describes conditions at.t he 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. t5ft•3I13 rMe 5 OMCW kqmfim Farrc Smsuraoe sewage Dwposal system•Page 1 of 17 �o �S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.•�''� 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. 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 Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owners Name information is every Stuartrequired for eve FL 34994 10/24/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 wM 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 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® g or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ' ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official 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 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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•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 7M 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 page. Cityrrown 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): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2014=59gpd Detail: 2015=82gpd Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): p y(gpd) Gallons per da Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records 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): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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: 10-15 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"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.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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: 1500Gal Sludge depth: 6-8„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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 Scum thickness 2-3-1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal H-10 tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 16" below grade. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 page. City/Town 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: ❑ 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 50B Pheasant Way, Centerville MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owners Name information is required for every Stuart FL 34994 10/24/2016 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is cleean and solid with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 22" below grade. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•�''� 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Infiltrators ❑ leaching galleries number: ❑ Teaching 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.): 6-Infiltrators with stone. Units were found dry at time of inspection with no staining. No sign of overloading or 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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.): t5ins•3/13 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 ,M "t 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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 t5ins•3/13 Title 5 Official Inspection Form: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 ,•''� 50B Pheasant Way, Centerville MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is required for every Stuart FL 34994 10/24/2016 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: +15' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger for unit A to 15'with no water encountered Max bottom of leaching is 4' 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50B Pheasant Way, Centerville, MA 02632 Property Address Chris Bullock 253 SE Wells Dr. Owner Owner's Name information is every Stuartrequired for eve FL 34994 10/24/2016 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 z t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 • LOCATIOAI : • SEW&C4E PERtAlT k1C VILLAGE � �L`.��-•�� L�-� �$�S— — INST LF-R�5 U ' E f~ ADDRES — DUIL;?ERS kJ E l*l A.DDRESS s C S / 04TE PERMIT ISSUED :�r ,� _ ,([-- D ATE COMPLI AMCE ISSUED: r r E T i 4 f t f ' i The COMM. Fire Department inspected the new construction located at # 61, or # 63 Pheasant Way Centerville. Because the road was not constructed in entirety in this 'area and the abutters are using an alternate access through a driveway easement,' they (COMM.) requested address changes for 3-4 properties. I'll try to keep this simple. The permit (I believe ) was issued for Map. 227 Parcel 143, a.k.a. #. 61 Pheasant Way. During construction, the owner had this parcel. deleted p ed and the land was co 63 Pheasant Way. All the land with the old house andnnew whouse aare 2now aall onrcel4Mapa227a # Parcel 142. Under the ordinance, when two or more buildings are on one parcel, they become unitized. The new addresses for these two homes are # 50A for the new house (formally # 61) and #,50B for the old house (formally # 63)on Map 227 Parcel 142. The others that were �..�, chhanapd, a3`P as fo7 loGrs:_ F.. Y