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HomeMy WebLinkAbout1109 SHOOTFLYING HILL RD - Health 1109 S�1oo Flying Iil� ��o� Centerville A= 19u - 22,3 UPC 12534 � o.2-153L0 AIM 1 - •6 . ( TOWN OF BARNSTABLE / LO!"ATION oT � =*WAGE#. VILLAGE ASSESSOR'S MAP&PARCEL 90— 2 INSTALLER'S NAME&PHONE NO. !6 \ �O d' /j�•�j,�/ SEPTIC TANK'CAPACITY / /i�o� �c�p--2a Z /O4 C� LEACHING FACILITY. (typee)/a2 (size) NO.OF BEDROOMS OWNER PERMIT DATE: 1 1-1 o 1 COMPLIANCE DATE: 11—Io•-aJ 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 r '== �7 �6 y� ��� ��� �1 ! -29 A S - sus �3.� -�7S aS-33 R3 - 33 E6 - g° 52- 3�8 g-6 -3� g- �' . 563 TOWN OF BAB.-NS'TABLE 5w�c I� -. - ,........_. A,SSFSSOWS MA2, dl��TFr:4�Lti'"DiAI l a'613PIE A10. �. h 66-®. ^/0-/6 (size),...., �.�...' N0,01� k� Ot�NdS:A 3� bu%mm opt owwu.,. TkTF) 'X`k7'_r. . ..�.A, �.... : f�li�l llF.l 'F �7'i:'i �. Saps�rtGon�Rsta,n�u I�rtUr�eia tine M�ximuml�djus�etl,GR'putadw£ttcd'l�l3le�atlaeBol►QraUiLeNc:hiri�l7rtr,ility ..—., P�lv�i�: 1 4 ►'a"apply laUl£z�ti Geat.;$�ing Pacility f C sly�,°lel9s exls2 fr"�.0 a�`e�tu ac Vi+;titi;tin AAA feet of ia£ashiritX .--�- .clu{^cy���/et9ant9 piatd .�acl�tti g� ci�i¢y tit'Any ((n t+iGl�£tb�Qp�c e2 t'lipaal)ing Pu�tl� / � [( 5 ° t r O � ' ( b A- c- aq ' e go A-G� 3` 7G ys' a No. aco �J�/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Nplitation for Bisposal Opstem Construction permit Application for a Permit to Construct( ) Repair Upgrade( ) 'Abandon( ) Complete System ❑Individual Components Location Address or Lot No. ��/� / Owner's Name,Address,and Tel.No� ��"✓• � Assessor's Map/Parcel Installer's N A s d e.No / 16av,1 D i e 's Name ress,and Tel. o./4 ,ram y ,����'� �� ��o X / �it Type of Building: Dwelling No.of Bedrooms Lot Size �� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided � gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 1i��/��.5 f 7 Z,20 Description of Soil �. Nature of Repairs or Alterations(Answer when applicable) E/ 1 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 Certificate of Compliance has been issued by this Board of Healt Signed ' Date Application Approved byAki VA Date Application Disapproved by Date for the following reasons Permit No. 2,001 361 Date Issued 1 f' 9 `C, �4 �'•:`r"�'_++.^.-�:...... �.,.,.^.:+•^-..%c+'1-.a" .. K�,.,r. .-,-_.... _..__-_�.....----....,,..: ,—...___- .....,-.-„.,,_.._,._,nw•--e, .-ti......- w -.r. -.,._:,w-:i,-.-.-.-� -. ,.. .. ..... ,r_.,,.� r^ - No. )00 `g Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r ftpiIication for Misposal Opstent Construction Vertnit Application for a Permit to Construct( ) Repair(v)grade( ) 'Abandon( )� r❑Complete System ❑Individual Components , Location Address or Lot No. Owner's Named Address,and Tel.No. Assessor's Map/Parcel Installer's Na;rte Address,and Tel,No Designer's Name Address,and Tel.No.% waltzile Type of Building: Dwelling No.of Bedrooms G/ f Lot Size r � sq.ft. Garbage Grinder( ) Other Type of Building :'11VNo:'of Persons Showers( ) Cafeteria,( ) t Other Fixtures Design Flow(min.required) d Desi flow rovided'r fi 1/, ✓ ° � ��'{ _x gP P ' 7" . gpd Plan Date Number of sheets )jRpvis on Dates;v'e, Title Size of Septic Tank La l�'j� Type of S.A.S. Description/oaf Soil' Nature of Repairs or Alterations(Answer when applicable) /��_:Gt� S /✓ � f• / Y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal.system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application A PP Approved b Y Date Application Disapproved by Date for the following reasons Permit No. ,,20?5 3(6 r Date Issued -- - - - -•--- --- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by ,? /~ at has been constructed in accordance with the provisions of'Title 5 and te for i hsV,,,—sal/ystem Construction Permit No. a o09—36/ dated 11- Q1- 0 /q Installer Designer #bedrooms Approved des gn flow�1 Lf gpd The issuance of is permit shall not be construed as a guarantee that the system will function as desi Date ' p (} Inspector j/l :x .S No. o`Z U�_36 Fee lt� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair([..ate �U% rraade(�) _Abandon( ) System located at�/1cl ���.�//i>�/ and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 .. � i j I f _.J r f i Nov 13 09 02: 08p p. 1 Town of Barnstable Regulatory Services Thomas F. Geiler, Director KAM � Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Oft ice: 508-362-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 11 1 Sewage Permit# Assessor's MapTurcel [d Z�3 c Designer: 1kyffM,\ ,"l Installer: Address: IkKo Address: ,S;�W!2 Vv)60 A44 Zk 0, -U;,ozS39 �. On f>� was issued a permit to install a ate) (installer) septic system at trG /n/G AA//Rbased on a design drawn b}. (address) Kd A jq Lre� dated I t 3 (desi tier) X ( certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as Lteml re:ocat:un of, e distribution box an&'or sepcic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of anv component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF r � ARE N t (Installer's Signature) No. 1140 _i C �1NITAIL 11I131 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO B)11L�STABt. PUBLIC HEA TH DIVI 1 N. CERTIFICATE: F COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FOR,�I AND AS-BUILT CARD aRF. RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DiV1S10N THANK YOU Q:HcaMSeptic/Designer Ceniticarion Form 3-26-adoc Town of BArnstable P# Department of Regulatory Services 1 v (9 Public health Division Date esuc • . "r"VL 200 Main Street,H*nis MA 02601 tfa uu'1 a- (J G 'Time Fee Date Scheduled i I Soil Suitability Assessment for Sewage Nsposal %� rL A ' 1 1* Witnessed By: `cr Performed By _v r / �'� i LOCATION & GENERAL INFORMATION Location Address .I () S�06T p� 6 {�,`/ Owner's Name DsTt-s•,Rr-- gt�K- 7 !1` l 31 We'T 52-0) 5Tf,,&$ Address Nev4 N qo�z Z 3 I Engineer's Natne De,,,-a^ M",� Assessor's Map/P4rcel: l NEW CONSIRU 'lON REPAIIt X Telephone# SOS 3rQ2-2�t Z2 E�l oe�Tl�I i Slopes Surface Stones ane Land Use Water Well Distances from: Open Water Body > 0 ft Possible Wee ?��.�ft. Drinking Area . Drainage Way ft Property Line Other ft SKETCH:(Strcet,name,dimcnsioris'of lot,exact locations of test holes&Pero tests,locate wetlands in proximity to holes) 1 Fs 41 tt / 10) och pit /n I - 9 1,pp�C ;�a took I a". ' ( �(hJ�� I --------�---- Parent material(gedlogic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Al 1 Weeping from Pit Face Estimated Seasonal Tjigh Groundwater N`g DtT- EKMVN TION FOR SEASONAL HIGH WATER TAME Method Used: I io. Depth to soil MORIN: In. Depth dbperved standing in obs.hole: groundwater Adjustment Depth toiwceping from side of obs.hole: t Adj.factor .,,._ Adj.dtwundwater LeVel.,,.,e, Index Well# Reading Date: Index Well level — I PERCOLATION TEST . Date_._-..._. 'I►' e Observation Hole# ' �" 64'' Time at G" ------ Depth of Pere ' uc 0 Time(9"-6") . — ------^— Start Pre-soak Time.@' i End Pre-soak Rate Min./Inch Site Suitability Asse$sment: Site Passed X Site Failed: Additional Testing Needed(Y/N) — ' e Com leted on Back---- Original:.Public Hed'lth Division Observation Hole Data To B P ***If ercola ion test is to be conducted within 100' of wetland,'youn untfirst notify the P _ __Y,:..:..:,,., a*lnact one(1)week prior to beg g. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nst tent gb ravel 42!_ Med.-G��.sP Z.SY 7 • S�„d DEEP OBSERVATION HOLE LOG Hole#_2 Depth from Soil-Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. 424 ,.(3grt2. S 7/ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil H izon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravell DEEP PBS RV f� ATION HOLE LOG Hole# IV Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) DA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Flood Insurance Rate May: Above 500 year flood'boundary No_ Yes Within 500 year boundary No x Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurrinc Pervious Material �? ' Q Does at least four feet of naturally occurring pervious material exist,in all areas observed-11ughout tr 0 area proposed for the soil absorption system? e5 If not,what is the depth of naturally occurring pervious material?�,. _; --� O Certification I certify that on D —t (date)I have passed the soil evaluator examination approi ed by the Department of Environmental Protection and that the above analysis,was performed by me onsistenUuith 52 the requi aini g,expertise and experience 10 CMR 15017 described in 3: . . N p° r-- . JA o Signature Date I � r� Q:l FrlCIPERCFORM.DOC )A viaG,) RQOA4- Z�X l2� i 0 SQ fee l 'g QCl R oo AA - !'t_x 2��I Set Fee7r' -��2 ��M'lLy A p-to2 meA i3tl}th ROOM- 7 x Yi B%4fhkOOM - x 6 = Z- LI sit Fier 7 69 SQcJAR� �N flReMd• DooR 6oY _ lu Of �c Q Fr Ile CT 77- 3 � 0 a 3 .J ' 3 � Boi LeR C fvRn�eael `s 5 i �v lZ SJI 6, DDOt U, AtOW ado wiN�ou. s L'i� C? to)te*r -r0i Lee qf sle P � 'fitt S T f.RO r»opNt rl rn eQN1m aLe P L A c•e, XA 10 /ram i k b O i F�� ati � I � .� 45 r\• vo w me o _.1 Qzi. F ca r+; S 1 1 _ 3 ` <� ? -Ak � 2 7E c In F I : Town of Barnstable Health Inspector oF'THE ro�ti Regulatory Services Office Hours 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 BAM STABLE, i Public Health Division 9 MASS. 1639.�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: December 3,2009 1. General Information: Size of Property: 0.46 acre Address: 1109 SHOOTFLYING HILL ROAD CENTERVILLE MA02632 Map 190 Parcel 223 Name:JENIFER EINSTEIN&CORY HAFLETT Phone#: 585-319-6968 2a.how many bedrooms exist at your property now?4 2b.Are you planning to add any bedrooms?No If yes,how many? 0 2c. how many bedrooms total are proposed at this property(including the amnesty unit)?4 2d.please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to PUBLIC WATER? YES 7. Is a disposal works construction permit on file? YES or,NO j Q 8. If yes,how many bedrooms were approved according to this permit? 4 Bedrooms r CD 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO =ate 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- W FOR OFFICE USE ONLY 3(O The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signe Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyappl.DOC Town of Barnstable Health Inspector pTHE t Regulatory Si Office Hours g yervces 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 • BARNSTABLE• i Public Health Division 9 MASS. 1639.�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: December 3,2009 1. General Information: Size of Property: 0.46 acre Address: 1109 SHOOTFLYING HILL ROAD CENTERVILLE MA 02632 Map 190 Parcel 223 Name:JENIFER EINSTEIN&CORY HAFLETT Phone#: 585-319-6968 2a.how many bedrooms exist at your property now?4 2b.Are you planning to add any bedrooms?No If yes,how many? 0 2c. how many bedrooms total are proposed at this property(including the amnesty unit)?4 2d.please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO, If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?� n ZM 5 . Location of.dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supper ells? M 40 6.. Is the dwelling connected to PUBLIC WATER? YES N 7. Is a disposal works construction permit on file? YES or N A 8. If yes,how many bedrooms were approved according to this permit? 4 Bedroo s — rn N 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETfERS\Blank Forms amnestyappl.DOC y , It a t v Exterior Deck -up--] 3'6 6'101 } 4-4 13'11 Half Bath A P,�,4 Kitchen Master Suite N ' Bath 8'10�-- �I �I uP ' is I. —2'4 f. v j cV i 1 20'4 —3'10— N in Living Room Bedroom Study/ - - '4 , r Bedroom 6 10'3 I, j v i j I 5'8 Main Floor ------------------------ ---------------------------------------------------------- ---------- -------------------------------------------------------------------------------; ------- ---------- —--------------- ---------= - la i Bath a— j i Bedroom Kitchen Bath i —S6 i. ' 1'8 1 T2 6,8 UP ' I i 11 Furnace and Hot j Water Unfinished - !-seater Living Room Storage Room L '± 277 �j Main Water Shut Off �I Fu;.hex - -- 14'8 6, Walkout Basment � THE r� Town of Barnstable Barnstable Regulatory Services Department ift"W edc$Cfl IARNSTASM Ass. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205008895 9/25/2009 Today Real Estate c/o David Holt 1533 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH_STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1109 Shootflying Hill Road, Centerville MA was last inspected on September 21, 2009 by Shawn McElroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T , Agent of WM the Board of Health Fy TOWN OF BARNSTABL. ,C3*.N 40V SEWAGE # MI AGE eem T1e-r-a +// ASSESSOR'S MAP OT NAA4E&PHONE NO. l•��✓� �— ;EInC TANK'CA.PACkrY ,EACF.UNG PACrL.ITY: (type) (size) C � 40.OF'BEDROOMS MILDER OR OWNER IE ITDATE: C:OhVLIANC E DATE: separation Distance Between the: Aaximtm Adjusted Groundwater Table to the Bottom of Teaching Facility met 'rivtate Wator Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 1 ;dge of We;dand and Leaclting facility(If any wetlands exist within 300!ee� eaci lung�i ) „Beet utnishca ley _ AL � p C 1 D P 30 OF '1 'P Commonwealth of Massachusetts Title 5 Official. Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA °; 02536 City/Town State '4 Zip Code 508-495-0905 S13971 ^° Telephone Number License Numberca ^� ca C1'y B. Certification , . I certify that I have personally inspected the sewage disposal system at this address and thMhe 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 9-22-09 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. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption.system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow El ® 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): 5 Yes No - n ❑ ® 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 CM 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1109 Shootflying Hill Rd Property Address Premiere Asset Services Contact David Holt To - - - da Real Estate 1 800 966 2448) ( @ Y Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ 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 official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 6-09Date 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: Last date of occupancy/use: Date Other(describe): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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: 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootfl in Hill Rd Y 9 Property Address P Y Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 16' 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 8"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: 1000gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 1" 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 15" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 9-21-09 required for every 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.): Tank is in good condition with baffles installed and no sign of leakage. 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.): 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): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 16 Commonwealth of Massachusetts F Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert . 1 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.): `I D-box has signs of hydrolic failure with back-up from the leach pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ 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.): Leach pit was filled beyond capacity at inpection with stain lines in riser. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I v � P-33r 1J- 3R . - - t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 1109 Shootflying Hill Rd Property Address Premiere Asset Services (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Centerville MA 02632 9-21-09 i 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: 20 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: USGS maps show groundwater at greater than 20'. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 r Exterior Deck P 19'8 3'6 6110 4-4— 13'11 Half Bath 'A Kitchen Master Suite N —Bath 8-10 no .i UP n L' (V 74 J a N 20'4 �I 710 ail � Living Room Bedroom N Study/ '4 Bedroom 6 10'3 { 8'2 � —t k 5'8 Main Floor //vy Zak F/ i FExterio3r2wDeck] � P -19'81 3'6- '10 4'4 13'11 Half Bath o N Kitchen Master Suite 4pdI Bath 8'10 � O i F 0 -z'4 11 1 9' 294 � N 66 Living Room Bedroom Study/ - '4- Bedroom m '6 k 10'3 k 8'2 � k 5'8 Main Floor --_--- -- ------ ----------------------------- -------------------------------------------------------------- ------- -19 g----- ----------------- --------------- -------------- ----- ---- -— ----------- Half Bath � -I �I� 48 i� ,Li Bedroom O Kitchen Bath 0 F—3'6— 1'8'k 1T2 r° 6'8 - -{ UP T Furnace and Hot i Water __� Unfinished - Heater Living Room Storage Room i 2T7 Main Water Shut Off i � Fuse Box i 6, 14'8 ------------- I Walkout Basment Town of Barnstable Regulatory Services BAMSFABM MAW � Thomas F. Geiler,Director. 16�q. ti . Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 9, 2007 Alcimir Lopes 1109 Shootflying Hill Road Centerville, MA 02632 NOTICE TO. ABATE VIOLATIONS. OF 105. CMR 410.000, STATE SANITARY CODE II-MINIMUM STANDARDS.OF FITNESS.FOR HUMAN.HABITATION., THE STATE.ENVIRONMENTAL CODE,TITLE 5. The property owned by you located at 1109 Shoot Flying Hill Road, Centerville,MA was - inspected on May 8, 2007 by Timothy O'Connell, Health Inspector for the Town Of Barnstable. This inspection was conducted on the basis of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.300 and 310 CMR 15.00: There were a total of five (5) bedrooms observed in this dwelling; three were observed on the first floor and two were observed within basement. However, the existing septic system (permit # 79-503) was not designed for 5 bedrooms. It was designed for three (3) bedrooms. Although the Title V inspection which was completed on 5-2-07 allows for a fourth bedroom due to the amount of stone surrounding your leach pit. You are directed to correct the violations listed above within thirty days (30) days of your receipt of this notice by removing entrance door and by opening door-way entrance to bedroom to minimum of five feet wide opening within basement. This will bring your total bedroom count DOWN from (5) to (4) which you are entitled to under your current septic design. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. QA0rder letterMousing violations\Rental ordinance\1109 shootflyinghill Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. CaM7 THE BOARD OF HEALTH Donald Desmarais, R.S. Health Inspector Town of Barnstable Cc: Timothy O'Connell,Health Inspector QAOrder letters\Housing violations\Rental ordinance\1109 shootflyinghill 4 { Commonwealth of Massachusetts M— a3 Title 5 Official Inspection Forms �0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 v, 1109 Shootflying Hill RoadA Property Address ,ate Alex Cheglakou Owner Owners Name Information Is required for every Centerville MA 02632 11-14-18 `= ` page. City/Town State Zip Code Date of Inspection t^;�r 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. `uuttuun I Iu1np,� Important:When A. Inspector Information S"/ / gc{9� ��� .• " sy�ti,,j filling out forms � on the computer, ?off= use only the tab James D.Sears ? ; 'JAMES key to move your Name of Inspector bEARS • cursor-do not C v' Go the return apewide Enterprises key. Company Name 153 Commercial Street ����iqF 5 IN Sp. `�� Company Address '- Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 11-15-18 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time, This inspection does not address how the system will perform In the future under the same or different conditions of use. 15insp.doc•rev.7126!2018 Title 5 Official Inepecdon Form:Subsurface Sewege Disposal System•Page 1 of 18 abed xe:1 dH L9:60 81.0Z 2 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is Centerville MA 02632 - 11-14-18 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is two 1000 Gal. Tank piped in line- D Box and 20 chamber's 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank Is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doo•rev.T12512018 Title 5 official Inspection Form:Subsurface Sewage Disposal system Page 2 of 18 Z a6ed xezI dH L9:60 i360Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owners Name information equir do re Centerville MA 02632 11-14-18 required for every page. cityrrown State Zip Code Date of Inspection C. Inspection Summary (cons.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval If pumpslalarms 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 ass inspection p pact on 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: t6lnsp.doc-rev.725/2018 Title S OMciel nspeclion Form:Subsurface Sewage Dlsposat system•Pam a of I £ a6ed xed dH L9:60 8[02 6Z AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 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 mannerthat 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 t5lnsp.doo rev.7IM2018 Title 5 Official Inspecion Form:Subsuface sewage Disposal System-Page 4 of 18 t, a5ed xed dH L9:60 960E l•Z AON Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owners Name Information is required for every Centerville MA 02632 11-14-18 page. Cky/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criterla Appil cable 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 avlwpMwl��ii��less than 6"below invert or available volume is less than 1/2 day flow of fi 4 0f{/N4 ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a ce sspool ess ool serving a facility with a design flow f P 9 tY g o a 2000 gpd- ❑ ® 10,000 gpd. ❑ ® The system f1ft. 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 15insp.doc•rev.7/26/2010 Tide 5 DRdal Inspection Form:Subsurface Sewage Disposal systam,•page s of 18 S a5ed xe:1 dH LS:60 8 60Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information Is required for every Centerville MA 02632 11-14-18 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. 5. 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 Pr 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 NIA) ® ❑ 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)) t5nsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subs0soa Sewage Disposal System•Page 6 of 18 9 a5ed xeJ dH L9:60 8102 i Z AON c Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 per. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: (2) 1000 Gal. Tanks D Box and 20 Chamber's. Number of current residents: NA 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 ears usage 2016-95,000Gais g ( y g (gpd))' 2017-154,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present oate t5insp.doe-rev.712612018 Tine 5 Official Inspecdon Form:So4surface Sewage Disposal System-Page 7 of 18 L a5ed xe� dH 85:60 860E 6Z AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c �15v�� 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15,203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7128/2018 Title 5 Offldal Inspedon form:Subsurface Sewage Disposal Systam-Page 8 of 18 9 a5ed xe� dH 85:60 81•0Z 6Z AcN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name Information Is required for every Centerville MA 02632 11-14-18.page. Cityrrown 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) ❑ InnovativelAlternative 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: 2009 Permit # 2009 -361. New Leaching. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): Pipeing is 4"PVC SCH -40. t5 risp.doc-rev,712612016 Title 5 Ofr4al Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 6 a5ed xed dH 69:60 81.0Z 6Z AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 per. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: Tank 1 Tank 2 8" 18" 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; 1000 Gal. 1000 Gal Sludge depth: 3" 1" Distance from top of sludge to bottom of outlet tee or baffle 27" 29" Scum thickness 1 r or, Distance from top of scum to top of outlet tee or baffle B" 8" Distance from bottom of scum to bottom of outlet tee or baffle 17' 18 How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank's at working level.Tank #1 at 8" below grade.Tank#2 at 18"below grade.#1 in Baffle out tee. #2 in and out tee's. No sign of leakage or over loading. t5lnsp,Goc•rev.7Ra12018 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 0� a5ed xe� dH 65:60 8 60Z 6Z AoN r — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vie-wo 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7120=18 Title S OfAdal Inspection Form:Subsurface Sewage Disposal System-Page 11 of 1B L i, abed xe� dH 69:60 8 60Z 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form lii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owners Name information is required for every Centerville MA 02632 11-14-18 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cunt.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-46' Below grade w/cover at 7". Box is clean and solid w/no sign of over loading or solid carry over. ' t5lnsp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Z 6 abed xed dH 00:01 8 60Z 6Z AON I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont,) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Nok Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 20 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ inn ovative/a Item ative system Type/name of technology: 15insp.doc•rev.'/2612D18 Title Wfficial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 E6 a6ed xeJ dH 00:06 860E 6Z AoN 4'O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont,) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is twenty H-20 Biodiffuser Chambers. Ck D Box and camera out line's. Clean wino sign of over loading. 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.7M)2018 Title 5 Ofricial Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 VI• abed xed dH 00:06 i360Z 1•2 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owners Name information is required for every Centerville MA 02632 11-14-18 page. Cityffown State Zip Code Date of Inspection D. System Information (cost.) 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.): t5irmp.doc-rev.7/20/2018 Title 5 Official Inspection Form:Subsurface sewage Dispose)system-Page 15 of to S6 a6ed xed dH 00:06 960Z 62 ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form > Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owners Name information is required for every Centerville MA 02632 11-14-18 page. Cityfrown 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.7/20/201 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 g t a5ed YU dH 00:U S M 6Z AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address IF,-r Owner Owner's Name information is required for every Centerville MA 02632 page. city/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 P • r G1 0 46 C- by ' 1/ - - 7s 4 00- 36 y� -t'- .37 Sins 3/13 Title 5 Official Inspection Form:Suhsuriace Sewage Disposal SIRS•Page 15 of 17 �� a5ed xed dH l•0:0l, 8 60Z 6Z ^oN Commonwealth of Massachusetts Title 5 Official Inspection Form VSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Road Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth tqO righ 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: 11-2-09 Date ❑ Observed site(abutting P roabuttin Pe►tY/observatlon hole within 15 0 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: T.H. on Design plan 11-2-09 1 T-T no G.W.. Bottom of chambers at S below grade. Bottom of chamber's at 6'-6" above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126=18 TiOe 5 Official Inspection Forth;Subsurface Sewage Disposal System-Page 17 or 18 gl a5ed xeJ did �0:06 860Z 6Z AON I Commonwealth of Massachusetts Title 5 Official Inspection Form IF, Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 1109 Shootflying Hill Road J Property Address Alex Cheglakou Owner Owner's Name information is required for every Centerville MA 02632 11-14-18 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 4 checked ® G. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i 15lnsp.doc•rev.712812018 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 66 a6ed xed dH 60:0l, 8l,0Z 6Z AON 07 MR. TIVE ONCE OF E9v MONIOENTAL Acs F DFPAF.TAPiW- OF EN VTIRONTIVIEN71? �, ,bo z TrI7—F—3• � C <�P �I �O —NOS°FOR IjO�� R = PART A Proper Address: ©oTf Y�.✓qj X�i Owner's Dame: Ownees Address: Date of hs- er-tio n; Name of inspector(alesse printl���ia/��.2tir.� company Name: J�Ja : g Address: Y�.✓aiiJ /3 o�G Telephone Number: 0 3 6CERTMCATION STATEMENT 2 at this address and that the information r�-vorted I certify that I have personalty inspected the sewage disposal system below is time,accuse and complete as of th--time of the won.The ins�ion s.peFformed based on mar r-_using and experience in the proper and m air mmce of on site scwage ustcxn---I am a D€P approved system inspector pursuant to Ste® df True 5(310 CrMRJS-000)- The system: '00 ,P-asses CondioonaRy Passes Tl e etg Further Evabis Lion by the Local A.pp-.DvMj Authority Fails InsDecto-I's Sign e� S� The system inspector submit a of this inspection report to th:.A V aority{Beard of Health or DEI)within 30 drays of completing this inspetim If the system is a e system or has a design Bow of 1fthe gpd or geatsr,the inspector and the system owner shall submit the report W thr 2ppropxi2M regional office of lire DER The original should be sent to the symm ow=and copies sent to the baryer,if alsplicable,aced the appro'krMe- authority. Motes and Comments 11 Y3'his report only describes eon-�ons at the time Of h t�On P=!d under he can ditions;of use at e.a� time.This inspection_does not address homer the s,VSVSWI n will peEIMM iu the-i re"-der the sa:�e or different conditions of e:se. Page 2 of I I Via` fix , as'FORM FAU A Property Adder `! O rJ �/Iye T //rY/✓l ��i�� c iv s Date ofInsp_�on- °is-pectifan summary_ Checkt A wsp f C ' I�Zfbund any mean which inflicaes mat any of Tbefailure,criterk desc Ied in 310 Ov 15303 or in 310 CAM 15304 e3dst.A y i�nre crheyie not evaluated are indic�e3 lselosr_ Comment B. System Conditionally Passes: One or more system eomponems as described in the"Conditional Pas"section nod to be emplaced or repaired.The system,upon cornDletion oftbe went-or-repa,as approved by the Board ofHealth,will pass. Aiaswer Yes,no or not determined(i' T,1dD)in the f€sr-th ollowing statemerim If"not determined"please explain- The septic tank is I over 20 years old*as a sciatic�sl:� �mewl.or not}is stnact�saily unsound,exhilaats snbstaratial. 'ors Or ftuk tOme�tmmim=Sy -%U ifthe - existing tangy is replaced Wt h a c€ampl septic. " ' a Ib--B th- A metal seatic-mt is Wit pas b2sp won� � _�31y soun-d:,not lealds-a and if a Cif cam of COMPU<-O-e indicming that the tank is Ie ss than 20 yeas of avafla€sle- _ l ND explain: i Observation of , e baeiap or bra om L-- .lei in tbm_ "nn b=_ehse to bralom or` obstructed pipe(s)order batalrta,� led are dish box � tps. c �-rTr if( approval of Board of Health) breal=pis}-ar-- h-ped obstructiots is rMoved. _ distra-bution- m is . .-D a,plain: the syswm pumping mare than 4 tads a year due to.brbkm or obsiruct3 pipe(s).3€pe system WL11 pass inspection if apprmrat of the B of Eleaadx)_ broken pipe(s)are replaced obstructiort is moved ND explain: I tge 3 of 11 PAR property Address: S/I o o "7 Date of€uspection: s:ur€her�'e��:�ratr s 1�.egnia-ed Ly the�oaa d oA i��lg-�a Conditions exist which require funher evaluadon by the of Yealth in order a o determine if the system is wiling to protect public healda,safety or she environment `s. System w€ll p2ss Board of'Hea.fth d es in aetcordance-nth 310 CT-M 153 3N that the system is not ftmcfio in a er €ph, ill rwatect gnblic he h,safety and the err�rorrment: — -face w— Cesspool or privy is 50 fee€s s _ Cesspool or priory is 50 f a bordering vegetated wetland or a salt marsh 2. System will fail unless t Board of .eak h.(2nd ftbHc eater Supplier,if any)determines.hat the system is functioning in a aanner that the public L-ealtb,safest,a-,d envlr nn t: _ The system septic tank:a-ad soi soon system(SAS)and the SAS is witiain 100 feet er=a surface seater sup y or tributary to a sty water supply. _ The syste has a septic tank and SAS as the SAS is within a Zone 1 of a paablic grater-suppIY- _ The has a septic tank and SAS aud e SAS is within 50 fed of a private water supply vr41'. _ Th system has a septic tank and SAS and th SAS is less than 100 fee_beat 50 feet or more fsoni a private ter supply weW:T.Method used to det a distance system passes if the well eater analysis,petfo ed at a DFP certified laboratmy,for coli_form ba, .a and volatile organic compounds indicates that a well is�e from pollution from that�and th presence of ammonia nitrogen and nitrate ni�.mgen is to or less than 5 ppm provided diatm a other f ilme criteria are triggered.A copy of the analysis most ttaehed io this form_ 3. € Cher: Pave 4 of I l PT va ALr}} -' . .-T OFERITIF)CA-3 larope .✓ i t v ✓�� owner Date Of!Osta�Uu" re m alapfa sle �o�p�s�!"- i" '. Syje," a each aft ;'au $yT " -"'or"moo ?c� on due.to o osded or c3Gggd SAS Or�l Yes No of s � � �or�� COMP �e d or s�� �due to am;,�e;Ioa�d or / a kmP or��g of a use s� of �" d or eloped S� Io SAS or c®-ssPcsol -Mt vie �liquid��I in tie d� a€aa hox also e outlet cesspool I 6-3�?0 € ie si leim V-day Bow�Itaxta quid dep&i�z focal is_ess tip r WC)t dUe I clogged or o-��sa c pig)- p Ms-e than 4 yes in t 3st y -- ag;s wed - vi€sr y is be-law 13 ---Ou ad elevanc'p to a s��ee / po�ioa of o 09 few.€€f a �vMW s-l`,-ply ca mi Any pmd'on of cal or prr-�ry as a-tEi way°s IY-r Is-w; " a Zone i a a public Well. 11_ y po an v, sspooi or 3 iz�d f3 aft o€a P- ale�atzr sci6 fe y poa3ion of a ceSspDoi car pr�*y �l� b�� �feet i��rpnv��a<at" AuY pow of a resspwl car pt'�is-Ie� s�m ;��e�.�¢aa� a�al,'sPs, s�agply III�]no ac le m- r3'-�' rIa aa���aala g age ec a ��s a a wed la ra -Yy for�31 ® md p mm.Of a aea a indicates � e erect I -fin f R-imogeu and ate t are e A€o e east as Cy esNo)The system aa�I i sbe o si d cr rise'3caard of desm-bed isa 310 CkAR 15.303,� e Health to detzrame what-will be naves} a,a Ste- �zIIII d lea �,#10� To be co � s �asst in - eiti: spr "to each of th -%ollOvmZ DIY ss addsa W€hamea 3 (The folio . tr ye^, no E3 met Of a �aa st�galsiy �e sy�-.a is` - _ drt�€dag I the s3sstem 209� aas�a`�t£s der sip� the sys islocs3:ad in a� Wei��PraW aQ� reea-�"PA)or a ri.- d zone II fa public weeftaer seappl -well Bred a s �bhr or M'Swm ti IF�(ou ha an ",yes'to�� 3�!bon ee E ?e sys€eM s ci�sngsSd _any Pam Win,considered a °yes''in 5e-ioa33.2�scve-the l��s}'sue has a �, cz gith 310 Ova si_�inca ilLs� under-Secsom R CT Bd 108 - i w e e s� T?e sy$ as ea'shed LO=Ct the a �ip��� a�5ce of the�etia eat 15304. 'Page 5 of 11 �zriz K S F.��tiSeTiC,1 J F`-��2i`$E :Y 0�`:`i, nF F0 _ .�,. I- A¢y 1� .1p i`�dy T E Property,A ddlr.a//0 00 r Owner: P/C I lyate of inspectior3° Check iftlle folio have bxn done_ ®u s: irate yes'or`no'as to each ofthe follot�ran$: Yes jo Pumpiaag information v'as p,-ovidasl by the ovrca:,occupant,or Board of Health ere any ofthe system components pumped out in the previous two weeks / Has the sybm received normal flogs in the previous two week penod? Have large volm nes of vrater been introduced to the system-,ecently or as part of this inspection SAtere as built plans ofthe sya€em obtained and examined?(Ifthey Were not available note as NV A) fWas the facility or$vaelling in'rspected for signs of sewage back up? Was the site inspected for sians of break out? 7— Were all system components,e-.cludhng the SAS,located on site? or rWere the septic tank manholes uncovered,opened,and the interior ofthe tank inspected for the condition ��b -esortees,material of cons�3stion,dimensiofs,dleptia••of lidltsid,depth of sludge and depth of scum Was the facility owner(and occupants if diFferent ftm o+per)provided rvrtb utzfor€n3uon on the proper maintenance of subsurface sere disposal systems'.) The size and I*mtioxg of-the Soil bsorptian 5y'sten(SA. ®n the site has been Bete, in based on. Existing information.For e.,natnple,a p at e Board bf Healer _ Determiined in the field fffaxiy ofthe fa-ilurre c-rit ?=elated€o Part C is at issue approximation of distacdp, is unacc_epmble)j310 CMR 15302(3)(b)] Page 6 of I I FLART IFEM TFO O Property Addrws;/�/o Owner./-)//nl /"L !Date of hmpection:�.> 7 FLOW COINDMI ONs IESIDENTIA Number of bedrooms(desiLm): Number of bedraoms(ac€aaal): DESIGN flow based on 310 Uj 3(far¢mmple-110 gp4 x-#- L bedmaxs): � Number of current residents:^� Does residence have a garbage grinder(yes or no)-/- Is laundry on a separate sewage system(yes or na): lf yes separate iuspection regaired] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water mew readings,if avaal-ble(Last 2 yeas age(gpd)): /v Sump pump(yes or no):_ Last date of occupancy: COABIERCIAL11NDUSTRUL Type of establishment: Design flow(based on 3I0 CMR I52 : apd Basis of design flaw(seatslpers�esQr Grease trap P t no): Industrial waste holding tank . Non-sanitary waste dis ed to the Title 5 system(yes or no):_ Water meter readin ' available: Last date of occapancyluse: OTHER(describe): GENEMkL UTATI Pumping Records Source of Mormatlon: J._ I Was system pumped"as part of the inspection(yes or-no)::' Ifyes,volume pumped " Qalions—I1oe� fj•ape$ d`�'- Reason for pumping s ' Ty eptic tank,distribution boy,so-Il absorption Usm—, _Sing cesspool _ Gverfiow-cesspoor —ivy _Shared sysmw bpes ormo)(if yes,zttack pra if anyj- _InnovativetAlternative technology Attac€xa*y of the current open®n and maintenance-contest(to be obtained-frorn system o-wner) —Tight tank- ^Mach a copy of the DEL'-approval _Other(descr..-be): Approximate age of all comaonent_s,date installed(if Imown)and source of information: Were sewage odors detected-when arriving at the site(yes or no): p�e 7 of I I 0 T IN I c_VA_L R-I SYSIM 00 Owner- D-2te of inspe--. Dibelowgrade- W lL _2 I viaterWs of caas=actio= Dimnce ftm pAlvale vr.=mWly well or sacdon Mle: yar a, of leak Comments(on ccMEOM OfjO S=C (Io=afi-_an snE.-plan) Depth below mde- -C 0�_C_ Meml lo.=rial Of COW-MIC nc _jh poiyetia ?erne her C--d5cam of COM-Plian=( es no)- f Mnh is metal rM agge: Is age certrff Cate) S ludse depth 10 17 -1 Dis=ce ftm to-p of slude--to bottom ofoudez tee or baff Le: Sam 1hicimess: W D7.stance:aom top of s=m to top of offence or baffle: C7, Distance ftm bou-m of wm to bOuOm Of OWdzE zee or ba—Me: liquid lavils C-c._ _,enLts(on pm3p7jj�g ha and nouBet tee or haffli�t candi=- orsE, crLrr--J immVil"VI _q, ja as r,-Iz:ed to oudet mverts,evid—m-ce ofh-,_-ka�etc-)- GREASE TRAP:_(10CM oun sim pl-=,) Depth below grade- - Ayeffiylenne other el. metal Irrib pc (e�a . )- S..-M Dist==kum top of smnm to tal5 et tee or e: Distance 57om 17,�of S _ M b Of Outha tie or bafffla: CU t- 'di Jig evtls 7,5 CC auuleL maz�05- 0 cor aga, Page 9 of I I PART c - g, pmbperiyA i- , C ie.TEGL vE ll.�- Depth below fie- iPusion Capaciq �s alsa A prser (yes o£�o A; I�re3 i _MAer Cves�no)-- Dam Q; pummpmg -aMM�( won am m3,—i flees sc$e , Depth o;iagtdd level above ouUer ine%F j: 15 tee=(ncm of box is Ievel and dis * -om ao Dud.—€4a 3 esT ��to sQiids �z e��� ]eaka_a ins sr cur of box,mc.)- HUMP CFIM e Cocne oaa /j i`un�s m�order Cy � - ianns in WorI;�ng order(yes or Ct�n5inemts(mote sohd—ftint'f_ p2ge 9 of I I -4 SSEDS-IR Y- I—E.-PITZ1Z ON FORM-NOT FM5­1XIONT _,-,SURFACE SEWAGE Dispo,&A 1,SYSTEM EqBM=ON FgRM A-P-T(C /-,c V!t-A Q- v//,Lc- f-,2 -09i BOt T S V-S. �-Rrl�-s--A a- ) ��E p S 2g,C--T Z 2 72� Soa,A-BSO m%-R. 1fSAS wrtlecamd e-5,7-hain-why: Type pits,nmnbr- J leachmg abets..number- leacbdag-gffip-Hes,number- leaching vmclws,ntmber,lengdL- leachmg7fiields,--amher;dumeuw= avm-Bovrc--spovl,n=ber ianovatividah=adw sy5mir Tyl--imme of ze�-ndagy-- Coruments(nole-can-didawof -cm-flure,Ileval of ponrii"- da-map sciL condition ofvagcDmon, etc.): ILI CESSPOOLS: -I=ne on site plan) CESSPOOLS:_(cesspool urast be part of mspecrion)k Number and conEoeuxa- . Pum7 Depth-top of liquid to- et invemsc Depth of solids layer. Depth of scum layer z Dimensions of CL--spool: Materials of constxuation: Indicatir", of ggmundv—mer bw or no): ,of C--m-ruents(note ccmeuzion f sodst-vis fj." z 7­-,Cc, y draL PRTVV-: (locate on s ola-vi). Dimmasions: commew-s(note cand-do n Vsoif'siP of Ir-w'c- Page 10 of 11 07 TER �Ly,. '-";j �9 .ate {,,-y-s,s-,,c ..- ;s.�_1=�,�.s�_.._iX+o_. 7�.-.>�i�c e. �'�rage faa�ht "' / '-'7/ of Inspeaff-m: t rovide a s�tch of the svyage disposal System beunchr3ae�Locate afl well§ few 1,�ac� why cP 1seewers i j ti Z,/O Otp G 2 �2�v �� 23 L— //)= XNspEC.7L-AGN FORM--NOT FOR VULUI-.I Jul,' PARTS STEM R OPMAnON(contimed) Pi o?erty A Owner. L?am omvediD= SITE EXAM SIC= SID-�tce wa m Cbsk cellar Sbaiioes®sells Fred depth ro gerumd watm. feet Plem mdicam(check)all memods used to die the huh grm and water.elevaii m Obtained#'rum system desk pbns cm rmord-If chedmct dace cEdesimPlaa aeVie -. Ohs-mved sft(abutting propez ylobsmv=m hole withm 15D Ject of SAS) Checked with local Bcmd Checked with loci excrvan3m,histaller, (attach docummuata6gn) p Accessed USGS dam: To ui•� G.�a d .4Tt 2 �� You must describe how you estalidished the gromd Water elevafan. ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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. A. General Information 4 ��1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 u..r CN 10-24-13 Insp ctor's Signature Date r�. 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 ha4l i7design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the repo�to the appropriate regional office of the DEP. The original should be sent to the system owner h anj Z'bpies 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. III -Ills t5ins•3/13 Title 5 Official Inspe4 tiop VForm-Sub1surface� Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 page. City/Town 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 is in good working order with no sign of failure. 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 H Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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 Y2 day flow t5ins•3/13 Title 5 Official Inspecbon 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 wM 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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. I ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet P vY 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 Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ' Commonwealth of Massachusetts b v Title 5 official Inspection Form 'm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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: 10-2013 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 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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: Not pumped since 2009 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: New system 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 .h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 6"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: 2-1000 gal Sludge depth: 12" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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 20" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle5" Distance from bottom of scum to bottom of outlet tee or baffle 14" e How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There are 2 sepic tanks in a series. The above measurements are for the first tank. The second tank had no visible solids or issues. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ` Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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 M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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.): Good condition with water at working level and no sign of back-up from field. 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 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers t number: 20-16" biodiffusers ❑ 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.): Leach filed in good working order with no sign of back-up into d-box or surrounding soils. 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 M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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 A Lj 13 ,dq H Qrtl.� r r 'e 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 M 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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: Original design plans show no groundwater at 12'. 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 'm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M . 1109 Shootflying Hill Rd Property Address Cory Haflett Owner Owner's Name information is required for every Centerville MA 02632 10-24-13 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 DATE 5/30/06 PROPERTY ADDRESS 1109 shoot Flying Hill Road Centerville MA 02632 On the above date, the septic system at the address above was Inspected. This system consists of the following:. 1., 1- 1000 gaiion zept.ic tank., 2., 1-Dibt2.igut.i.on Bpx.,. . 3., 1-1000 ga eion .eeach.ing p.it.� Based on inspection, I certify the following conditions: 4 o 7h.iz -iz a 7.it 2e Five Septic z yzt em 5., Septic zyztem .ins .in pzope2 Wo tk.ing oade2 at the paeeent time., SIGNATUR / Name: Robert.A.-Paglini Company: Joseph P. Macomber & Son Inc . Address: P. O. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 ( -� r.� r r - • JOSEPH P. .MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped &Installed Town Sewer Connections P.O. Box 66 Centerville, MA..026.32-0066 775-3338 775-6412 • 9 •\ COMMONWEALTH OF MASSACHUSETTS EXEcuTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM NOT.FOR•VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner's Name: Jeanne Mullen Owner's Address: Same Date of Inspection: 5 3 0/0 6 Name of Inspector: (please print) Robb rt. :A P o.lini Company Name: 7. l.Aacoogea .S:o.n Ina- Mailing Address: .6 6 CzntzaVi e, Na —.6..02632 Telephone Number: 5 0 8-7. 7 5:3 3 3 8' CERTIFICATION STATEMENT I certify that I have personally inspected the.sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in.the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section.15:340 of Title 5(310 CMR 1&000). The system: XXX Passes - -Conditionally Passes Deeds Further Evaluation by the Local Approving Authority ajis Inspector's Signature: Date: 5v ,96 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 tolhe system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that �. time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION:.FORM—<NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORRM !` PART A CERTIFICATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centervil a MA 02632 Owner: Jeanne Mullen Date of Inspection: 5/3 0/0 6 Inspection Summary: Check A,B,C,D or E/ALwAYSvomplete ail of Seetion.D A. System Passes: y£S NO I have not found any information which indicates`ihat 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: Septic zyztem .i-6 .in paopea woAk.ing oadea at the /aeZent t.ime.- B. System Conditionally Passes: O One or more system components.as described in the"Conditional.Pass".:section.need to b.e.replaced.or repaired.The system,upon completion of the replacement or repair,as approv@d�by the Board of Health,will pass. Answer yes,no or not-determined(Y,N,ND)in the for the following sfi lements.If"not determined"please explain. NO The septic tank is metal and,over20 years oldt or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank,as approved by the.Board.of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection,if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled br replaced ND explain: NO The system requited pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain.: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullen Date of Inspection: 5/3 0/0 6 C. Further Evaluation is Required by.the Board of Health: No 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: ND Cesspool or privy is within 50 feet of a surface water lYQ_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety.and environment: No The system has aseptic 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. No The system has a.septic tank and SAS and the SAS is within a Zone I of a public water supply. No The system has a septic tank and.SAS`and.the SAS is within 50 feet of a private water supply well. No 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 vi siia 1 "*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure.criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullen Date of Inspection: 5/3 0/0 6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the followinglor all inspections: Yes No _ X Backup of sewage,into facility.or system component due;to overloaded or clogged SAS or cesspool X Discharge:or ponding of effluent to the surface.of the.ground or surface.waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2.day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS;cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100.feet of a surface w;ter supply.or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1.of a public well. _ X Any portion of a cesspool or privy is within.50 feet of a private�,pater supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50.feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well.water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than'5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached.to this forip.] No (Yes/No)The system fails.I.have determined that:one or mow.pf 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 1.0,000 gpd.to 15,000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water.supply _ X 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullen Date of Inspection: 5/3 0/0 6 Check if the following have been done.You must indicate"yes"or"no"as to each.of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week.period? X Have large volumes of water been introduced to the system recently or as part of this,inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X — Was the facility or dwelling inspected for signs of sewage back' p: — — Was the site inspected for signs of break out X — Were all system components,excluding the SAS,located on site? w X _ Were the septic tank manholes uncovered,opened,and,the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of-Health. X _ Determined in the.field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY r:. S; CENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM,:INSPECTI _M � PART C SYSTEM INFORMATION Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullen Date of Inspection: 5 3 0 0 6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of.bedrooms(actual): .3 DESIGN flow based on 310 CMR 15.203(for example: 1 10 gpd x#of bedrooms): 330 Number of current residents: 0 _ Does residence have a garbage grinder(yes or no): n o Is laundry on a separate sewage..system(yes or no):no [if yes separate inspection requir. Laundry system inspected(yes or no): n o Seasonal use:(yes or no): no . 2005._28, 000 gcai-eon,3 GP D=76.i71 Water,meter readings,if available(last 2 years usage(gpd)):20 0 4=2 9, 000 ga on y%!0=7 9. 4 5 Sump pump(yes or no): n o Last date of occupancy: 5/15/0 6 COMMERCIAL/IlUSTRIAL Nl A Type of establ1isiui ont:. Design flow(la ed on 310 CMR 15.203): apd Basis of d. ign*-'flow(seats/persons/sgft,etc.):, Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system.(yes or no):_ Water meter readings,if available: Last date of occupancy/use: . OTHER(describe): GENERAL INFORMATION Pumping Records — Source of information: NIA Was system pumped as part of the inspection(yes or no)n o If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records, if any) -Innovative/Alternative technology.Attach a copy of the current operation and mainte,,'.nc•. Tact(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known).and source of information: 20/lea2.6 Were sewage odors detected when arriving at the site(yes or no):n Y 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullin Date of Inspection: 5/3 0/0 6 BUILDING SEWER(locate on site plan) Depth below grade: 18 Materials of construction:_cast iron X 40 PVC_other(e�plain): Distance from private water supply well or suction line: �� Comments(on condition of joints,ventin ,evidence of leakage, h etc.): g vent., joint-6 ace tight.) . No ekage., Vented thtou 200� SEPTIC TANK S (locate on site plan) 1000 ga. i o n Depth below grade: 6" Material of construction: X concrete_metal fiberglass polyethylene _other(explain) A, If tank is metal list age:_ Is age confirmed by a Certificate of Comphanee(yet or no):_(attach a copy of certificate) Dimensions: 8' 6"X5.'8"X4' 10" Sludge depth._ 2 a c e - t a c e_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: t a c e Distance from top of scum to top of outlet tee or baffle: t as c e Distance from bottom of scum to bottom of outlet tee or ba�a c e How were dimensions determined: m e.a z u it e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels as related to outlet invert,.evidence of leakage,etc.): D'Imn tank eve2 2 ea/zz-, Iniet 9 outQet tees a2e in _ .gaee., 7ank iz ,stauctu2a�2 �oundo GREASE TRAP:NO (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain)`. Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recomm endations inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 2ea�e tea i� not 2e,3ent T Page 8 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02632 Owner: Jeanne Mullen Date of Inspection: 5/3 0/0 6 TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_,__polyethylene rother(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working.order(yes.or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 7igh.t o2 ho.2d.ing .tanks ace not /22e6en;t DISTRIBUTION BOX: y ES(if present must be opened)(locate on sitd,Fpian) �-.. 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.): Box .i.6 2evei., Kaz I ;a.teltae., No zoe.id ca22youve2 o2 eekage .in oa out o- R'ox ) - PUMP CHAMBER: NO (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): PumI2 cahmfle.¢ .ins not paehen.t 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS - . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1109 Shoot Flying Hill Rd . Cen ervi e . MA 02632 Owner: Jeanne Mullen Date of Inspection: 5 3 0 Z 0 6 SOIL ABSORPTION SYSTEM(SAS): -(locate on site plan,excavation not required) If SAS not located explain why: Located .see 12age 70. Type X leaching pits,number: 1 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.): Loamy to medium -sand., No z.ignz o� �iaiu2tk,..oz 12onding., So.i.ez ate 2y., eye a .ion .cis noama CESSPOOLS:NO (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: - Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce.3.s1?ooiz aae not aesent PRIVY: NO (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.): la ivy .i s not P aeheat 9 Page 10 of 11 OMCIAL INSPECTION FORM . NOT FOR VOLUNTARY ASSESSMENTS i,. SUJISURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM —� . PART G SYSTEM INFORMATION(continued) Property Address: 1109 Shoot. Flying Hill Rd Cen ervi e MA 02632 Owner: Jeanne Mullen Date of Inspection: 5 3 0 0 6_ SKETCH OF SEWAGE DISPOSAL SYSTEM ProYide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. . p�� ` r fPlLL R� 10 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: 1109 Shoot Flying Hill Rd Centerville MA 02.632 Owner: Jeanne_ Mullen Date of Inspection: 5/3 0/0 6 SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water ( ® feet Please indicate(check)all methods used-to determine the high ground water elevation: -N 0 Obtained from system design plans on record-If checked,date of design'plan reviewed:. y e.s Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local-Board.of Health-explain:e7 6 9,aift caizrl no Checked:with local excavators,installers-(attach documentation) Accessed USGSdatabase=explainhttRr own.,karmsta8.2e,-me,9,u!s ,4 You must describe how you established the high ground water elevation: Uzed Cage Cod Comm.izion Nate2 7ag.2e' Contoua_.s And %uk-eze I.Jate2 SuP12.9y 1Je�2 head �aotect io•n a2eaz map., Sept 1995 1Jate2 2esoa4ceh 0.411ce cane cod comm.is.aon Leaching Pit feet Groundwatt ee e w F t B to Bottom..,Of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom qL O of the leaching pit and the adjusted groundwater table is �I feet. 11 � fiinr.r••} TOWN OF ARNSTABLE BOARD QF 1IHA1 TI1 _SUIISURFACR 81;WA09 D18POiiA­1# SYST4M ItISPRCTION BO{tM - KART D CERTIFICATION ..�. . «.T,.,.T•5'1S.-+wM• MGM - -TYPE OR PRINT MIA— ' PRQPERTY INSPCCTE47 STREET ADDRESS 110.9 Shoot Flying Hill Rd Centerville '02632 . A•SS•ESSORS MAP, BLOCK AND 'PARCCL 11 OWNSR's NAME Jeanne•-M.l.len PART` D 0RR1'IFI0AT3QN .. 'NAME 'OF - Robert: A Paoiiln , INSPECTOR . COMPANY NAME �Tcrat�h "p ��mb _._.�.. COMPANY ADDRESS ` P.( ox : 66 Gr teruille M 'Q232-0066 sts• t Tovn-or City. Sta • LIP COMPANY TEWHONE i 508. Y 7.5 3338 FAX (' 508•1179'0 f 578 . C8RT-ITICATION. STATEMENT I certify that. I have persodal-lY .inspected ..the sewage digpopi system at this address and that- t1fd' information reported •ia true,. a e0rate•i acid omplete as of the time ..Of 4Wection..• The in$peQtJo.�n was performed and any recommendations regard.ini. upgrade., .maintenance ,- abd repair .afie• coneis'tent with my trainil1,9 and exp.e-risnce in th8. ppoper furrcti,'on- and maintenance of on- site sewage d48po641 sy$"ins" Check one; XXX Systeni PAS D _ The inspection Which •.I. have conducted has .,n•qt found any information . which indicates' that- the system' fails to ' adecivately. protect .publiv health or the env i,.ropment as defined in. .310 CMR. l i30.3•, -Ally failure criteria r16t eyaluat'ed are as stated in the FAI•LUIM- CRITTgRIA :seetion et this, form. System FAILED* The inspeatioh which I have condttted ,has found that •the System fails to Protect the public health and the en4ronmen•t ' in acoo'rdance with Title 61 310 CMR 15 . 3031 and as specifically noted -on .PA'RT' 0 FAILURE CRITERIA of this insPec'ti.on .form. ' Inspector Signature* .____._. 'D4te Yn4' copy of this aerti,fi.oat•ioh must •be yrovIded ,'to the .QWNMI t�+9 BUYER re up 1L.oa�ble) and the 13QARD 08' HEA TH. •, ; » * it the inspection FAIL'Eb., thb .owneV .or �operator system. within o'ne year of the da•t•e of the inspection, unless. allowed car- required - r%t.hRrwdse. as provided ill qA0 CMR • TOWN OF BARNSTABLE i G _e LOCATION /��7 d I SEWAGE## VILLAGE �a �t-t- SESS 'S MAP&PAR EL SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDRO S OWNER �P PERMIT DA COMPLIANCE DATE: c 0� 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 FIIRNTSAED BY - e O - < of 1 ATION 10 7 r5 11 TOWN OF BARNSTAB LE SEWAGE#��Q - VIILAGE1e ASESSOR'S MAP&PARCEL INSTALLERS NAME 8 PHONE NO. 0 f.. SEPTIC TANK CAPACITY /b00 LEACHING FACILITY.(type)� � (size) zoo NO.OF BEDROOMS ) OWNER a > PERMIT DATE: & 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 leachingfacility)ty) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY `� � 9 � Hda� FLy /.� � /il1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYicattou for aigpogat �&pgtem Cougtructtou Permit Application for a Permit to Construct�51�29h%ulb ( ) Repair q Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �e 11 r Owner's'0Na�meMA�ddres ;` Tel.No. Assessor's Map/Parcel JC D Pa3tI ��®q L�� G� �'1-25�333 aT Installer's Nam ,Address, nd Tel.No.( � Designer's Name,Address and Tel.No. J � o f7 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank (oo O Type of S.A.S. Lem Description of Soil Nature of Repairs or Alterations(Answer when applicable) aGQ, D - tG 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 Certificate of Compliance has been issued by t ' of alth. Sign Date / Application Approved by �;44yjfeef Date Application.Disapproved by: Date. for the following reasons Permit No. Date Issued ._ ------------------------------- No. � '. Fee Entered in computer: e THE COMMONWEALTH OF MASSACHUSETTS p T PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Migonl q§pgtem Cow5trUction Permit Application for a Permit to Construci( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components �101v�41�u1 Kt1� rd Location Address or Lot No. 10 I}� _( Owner's Name,Address,and Tel.Not. Assessor's Map/Parcel 1 ( t1Q C 'u lkt� �I -�((3 l"' _ X► 0. Installer's Nar!�,e,Address,and Tel.NA ?7� ��� Designer's Name,Address and Tel.No. ', Yl LPI�Cf�YI'1 ,"— p W 0 o Yl',,� w �o G ON QE c.-Qm�r�t.111 V� V t ll> Type of Building: Dwelling No.of Bedrooms .� Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date . i Number of sheets ram_Revision Date Title Size of Septic Tank (D0 0 Type of S.A.S. Description of Soil a Nature of Repairs or Alterations(Answer when applicable)kx cacx_ _ - So)( Ck} Date last inspected: Agreement: f A 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 Certificate of Compliance has been issued by this. and of Health.— t Sign (. Date ( >✓ ��[' "Application Approved by v I"��,i'Q��i '.l �//_ Date Application Disapproved by: �( Date W for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( by4 f6ol o "1. CUI ( on at t 1 Q Q ,00WW( 1 G tI( f,j I Y has been constructed in accordance with the�poor))ovisions of Title 5 and the for Disposal System Construction Permit No. dated Installer�(nQ�� (� � L,4'1 I Designer #bedrooms Approved design-flow< gpd The issuance of this permit shad,l,notideikonstrued as a guarantee that the system{will function,as eyigned. Date _ Inspectors T -----&201/9 ------------------------ --___—— _ No. / �J Fee /���_ C/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpozal �&pgtem Cow5trUction Permit Permission is hereby granted to Construct ( ) Repair �pgrade ( ) AbandonSystem located at O ��l'1,O0 l! ( 1'1 _{'. t �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: Coon s 6tio must be completed within three years of the date of this perm Date Approved by (71) No................ ................... THE COMMONWEALTH OF MASSACHUSETTS —�--� BOARD OF HEALTH ..............OP... Applira#ion or Dhipoii al Workii Tontitrurtion rrrutit Application is hereby made for a Permit to Construct (<) or Repair ( ) an Individual Sewage Disposal System at: ................--.................. . -•--•-•..........----------........... .......•-•-----•-••....•--...........LQ' .. ------ Location-Add s !.t No. A I L L r (QOw�ner y.� p Address W ......•-••••......... ..... .'.. 1a.�!J�f1ZJ= ............ ......... -�`_�eL..�. r..t .V....Z_L. .._.. Installer Address ry PQ d Type of Building Size Lot_ �y._ ...Sq. feet U Dwelling—No. of Bedrooms...............13.......................Expansion Attic ( ) Garbage Grinder ( ) ..•... No. f persons---------•----------•------- Showers —p., Other—Type of Building ............... p � ( ) Cafeteria ( ) a Other fixtures . .._..----••. ............... . • ..- W Design Flow.............J`� ......................gallons per person per day. Total daily flow-------------—3.. ..........gallons. WSeptic Tank—Liquid'capacityf®U0.gallons Length------ Width..... .___. Diameter_............. Depth...... x Disposal Trench—No. .................... Width........._---------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/........... Diameter......49... _.__ Depth below inlet........ Total leaching area.Z®Q.....sq. ft. Z Other Distribution box ()') Dosinytank ( ) '—' Percolation Test Results Performed by._. _ �.Q�. .c......�0� Co '7'—/ ?"" 7.j a . .... -----••-- . Date -------- - ----------• ........ Test Pit No. 1 .._ -__--minutes per inch Depth of Test Pit....lg4.... Depth to ground water/VV.7_ eArA— Test Pit No. 2!5;L •_....minutes per inch Depth of Test Pit.................... Depth to ground waterCO VA)TCRIEb ............................................................................................................................................................ i Description of Soil !s 0 -------------•--.......•--- ---------•---------------•--------------------------...-------------- W UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------------------------------•----------------------•--------------------------•--••--------••-••-••--•-----•-------•--•-----.....---••••-----•--•-----------------------------••------........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I i.y p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be&issedhe board woffhhealth. Z�ate----------------------- 7, Application Approved BY ---•-- ........................ ••--7................... ....... Date Application Disapproved for the following reasons:-------•--------------------•---------------------... .......................................................... .................................................................................................................................... ------------------------------------------------------------••-•-- Date PermitNo...............................::........................ Issued....................................................... Date .._ .. Fps.. No. , �► .Q...,....r. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF... .,(.`:?1.,C.tf J ."'_.'. 6...................._....... lipliration for Uhipo.4al Workii Tomitrnrflon rantit Application is hereby made for a Permit to Construct.( ) or Repair ( ) an Individual Sewage Disposal System at: ...................................... . .............. °_ ........................................ Location•Address or Lot No. ...........= L.. f' a'.... _--------- ^ .... ---- Owner { Address Uer Address 1 U Type of Building Size Lot. '!O; .._.l1�2_..Sq. feet Dwelling—No. of Bedrooms...............'3-___-_-____---_____=__-_Expansion Attic ( ) Garliage Grinder ( ) pal Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p, Other fixtures -------•----------------• ..--•• . W Design Flow.............%fr.S....................gallons per person per day. Total daily flow-----,...... 7.3---c7..............gallons. 1:4 Septic Tank—Liquid capacity/Qn,->.gallons Length....._g--`-_-. Width...... Diameter_______________ Depth..... E Disposal Trench—No.•----------------•-- Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.._.---/........... Diameter......&_`______ Depth below.inlet.......f__!..... Total leaching area.Z(—)o......sq. ft. Z Other Distribution box (jr-) Dosing tank ( ) `-' Percolation Test Results.''. Performed by._(�6;-Oye--� - ___ �p_�-__ Date.._! ,aa Test Pit No. .....minutes per inch Depth of Test Pit---- Depth to ground water;-L,�r;_ Gi, Test Pit No. 2-;�f._7.....minutes per inch Depth of Test Pit-------------------- Depth to ground a --=----••-•-----------------------••............------------------•-----.........._.......----_...----•------------•----------•-•----•----•--•...-----•------ Description of Soil # .... , ...,_.../�±. � ........................... V /. ..._. ! ✓ _.!r' -- #' '� -•c••------•---- -•----•........---•--•--••-•--•--........................................................ W ----------•--------------------•-•--•--•---•-------••-•--------------------------------•-----------------------=-------------------------------------------------------1.....• ......................... UNature of Repairs or Alterations—Answer when applicable.____.-......................................................................................... -•--------•---•-----------------•---•----------------------•--•-•--•--•----------....--------------------•••••--------------------------------------=----------------••....--------•---••---•--•-•------ Agreement: The undersigned agrees to install the aforedescribed.`Individual Sewage Disposal System in accordance with the provisions of ITI p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. 4 Y -------------------------------- Signed........... •--th .,r---- -- Date Application Approved By_ . J'�` �.. , J�-----�-'�t-rate! -�------ Application Disapproved for the following reasons-------------------- `�._....-___..-_----:...............................__._____.__.._._.___-_._.__..... J . o Date PermitNo...........................: Issued. ......"•---------------------------------- s - t b4 e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF............ . . ....................,. , . .....t...... difiraA unto nrr -- I THIS IS T CERTIFY, That the Ind vidual..Sewage Disposal System constructed ( ) Repaired ( ) b ' Installer at ... ` : m ----- ,� , #, ------------ has be In tailed in a' cordafic ith fl p>fc�vis4,�, bf.'i'1'' o !I fie ale"Sanit o e as cribed in the application for Disposal Works Construction Permit No. -------------- dated__-..__ _ a� ... THE ISSUANCE OF THIS CERTIFICATE SHUT BE CONSTRUE®:AS A GOARANTEE TWAT THE SYSTEM WILL FUNCTION �� FACTORY.---._.. InsPeDAT .................... ... J � r .' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .................. "7)4t14,3... .. ...N . ! n............ ",FEE..,FEE.. ...... Disposal Eprb Tnnitr inn rrniit Permission is hereby granted. = '........;;;,-----------------------------------------------•--•------------------------------.............--•--•-..... to Construct. ( or Repair an > > al ewage Disposal Syst at'No.-- =-- -- --- ----•--- . �•---••--....... --- ...j .. ......... , ` as sho non.the apphcarion or posalJG1-or s Construction P it No..................... Date ' 1. DATE---••----.-..... t .hW � v/ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - t SURVEY REFERENCE: LEGEND ' q PLAN OF LAND BY EVERETT HINCKLEY, PLS E L 1\\I C` H !\A A ID r Il\ c PROPOSED CONTOUR P:-,Ii 1 - SPO-1- C,ICJ' t_,OI\I SITE o2 DATED: NOVEMBER 1969 t G DECK UPP`0 T ,':. 58 6 1 ® PROPOSED SPOT GRADE- - ,;- `� —— 98 —— EXISTING CONTOUR E B.=..RN5.T,L BLE F GIS DATIjI\q Of Mgss + 96.52 EXISTING SPOT GRADEIj D q W— EXISTING WATER SERVICE �/ l II ARoN lN• TEST PIT A No. 1140 GREAT P�, ✓ECG /r\� // 1 �� MARSH ROAD S4NITAR\a �I�� I 1 I ✓E✓1iv , 1 / Existing Leach Pit 52 � LOCUS MAP N.T.S. \ // (Note 10) I` r / ,�' ----- ;; GENERAL NOTES: \ // �^ /�-�L- '/ �/ T 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ` \ 20 / BOARD OF HEALTH AND THE DESIGN ENGINEER. c_ WATER i 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS J,wATE j OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPUCA13LE 7 \ / /Existing 1,000G rr 1 ___ I LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: 50 1� �' septic tank ( Z,. !- I � - 310 CMR 15.405 (1) (B): \ I Lj b Q1'; -- t• I 1) A 1.36 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING TO BE 4.36 FT BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) \\ 1 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 0 _�I j M lJ DESIGN ENGINEER. l i ! 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I I- � FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN I ( ENGINEER BEFORE CONSTRUCTION CONTINUES. L i V II U- 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. t 1 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF I THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ® TH_2 i 2 I tit HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. I i TH-1 I '7 ! U 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. i Lu 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED _ 1 I I _ _ / / / �• _ q� . j TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. M I I meal Pone / / L 1�i� T 1 Imo ) 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED. I 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION I I wnte 1-11.)2• I l AREA - 2 C O y,% s i � - I � 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY l I 1 -► I l l I 1 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING 14. ALL PIPING TO BE 4" SCH 40 CSC 1/8-/FT (UNLESS SPEC. OTHERWISE) 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 16. PROPERTY IS WITHIN A NITROGEN SENSITIVE AREA. If 60 � / 5� ! BED LRA D ' PROPOSED SEPTIC SYSTEM UPGRADE PLAN KIT = Bth = Bth ` KIT 54 = RM = � 1109 SHOOT FLYING HILL ROAD, HYANNIS, MA 52� LIV. BED BED LIV. unfin. MAP:190 Prepared for: Mike Dedecko RM RM RM RM LOT.• 223 Engineering by: Surveying by: SCALE DRAWN DEED BOOK. 21236 DARREN M.MEYER,R.S. Eco—Tech Envlrnnmentel 1 20' DMM BASEMENT`LEVEL EASTPO SA 81 (508) 364-0894 a FIRST FLOOR DEED PAGE.'11109 EAST SANDWICH,MA 02537 GATE: CHECKED SHEET N0. 508-362-2922 1 1/03/09 DMM 1 of 2 REVI510N 1 1/09/2009-ADD SECOND 1,000G 5EPTIC TANK NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:50.64 FOR A DISTANCE OF 15' AROUND THE Y PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED S.A.S. { ELEV. TOP � PROPOSED D-BOX FOUNDATION INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER (Existing Slab) OUTLET AND SET TO 6" OF FINISH GRADE �• = 58.a3 --� F.G,EL: so.o-56.ot G. EL.=54.St SET TO 6" OF -GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. `/ A /� � F.G. EL.=54.5t r--• F. F.G. EL: 55.0f F.G. EL: 55.0(MAX.) VENT 9" MIN COVER/ 9" MIN COVER/ BRING ALL COVERS TO W/IN :Y 36" MAX COVER 6" OF GRADE 36" MAX COVER L 20' L - 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) ' 0 tlX (MIN.) 0 S=I% (MIN.) 4"SCH40 PVC 4"SCH40 PVC A LLi1o" w INV. TEE'S ARE TO BE 14 INV. t0" 14 ; e 11.3" TO EL.= 97 4" SCH 40 PVC EL.= 52.0 TEE'S ARE TO BE INVERT 4" SCH 40 PVC INV. INV. :r GA = 72 EL- 51.75 PROPOSED INV.=51.05 4 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE = 32.0'/ROW BA LE GAS - BAFFLE I INV.=51.25 DB-5(H-10) INV.= 50.25 SOIL ABSORPTION SYSTEM (~PROFILE) EXISTING 1,000 GALLON SEPTIC TANK PROPOSED 1,000 GALLON SEPTIC TANK EXISTING SEWER OUTLET RESTORE VEGETATIVE COVER BACKFILL WITH CLEAN PERC SAND 75" TO TOP OF CHAMBERS I NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PLACE FILTER FABRIC PIPE INVERTS PRIOR TO CONSTRUCTION OVER ALL UNITS 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=50.64 (RECOMMENDED) GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 50.25 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 49.31 EXISTING SUITABLE 310 CMR 15.221(2) 2.83' MATERIAL 3) REPLACE EXISTING 1,000 GALLON SEPTIC 5' MIN. ABOVE BOTTOM OF r� 76" TANK WITH 1500 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' IF FAILED, DAMAGED, OR LESS THAN 1,000G IN CAPACITY. (7.06' PROVIDED) USE 4 ROWS OF 5-HIGH CAPACITY PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED BOTTOM OF TESTHOLE EL.=42.25-=- ADS BIODIFFUSER UNITS-NO STONE W/ CONTOURED WEDGE SEPTIC SYSTEM PROFILE TYPICAL SECTION - 16,. N.T.S. KM11� SOIL LOG • DESIGN CRITERIA DATE:DATE: NOVEMBER 2, 2009 NUMBER OF BEDROOMS: 4 BR EXIST. (PROPERTY IS IN NITROGEN SENSITIVE AREA) SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614 SECTION END CAP SOIL TEXTURAL CLASS: CLASS I WITNESS: DAVID STANTON, BARNSTABLE B.O.H. DESIGN PERCOLATION RATE: <2 MIN/IN TP- � TP_2 16'"' HIGH CAPACITY (H-20) BIODIFFUSER UNIT �` OF ,yfs Elev. Depth Elev. Depth DAILY FLOW: 110 G.P.D./BR �� 'r9�, 53.75 0" 54.25 0" DESIGN FLOW: 440 G.P.D. (Min.) %g$� PARR y MODEL 16" HICAP GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) O ME ER / FILL FILL LENGTH 76' NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY " No. 1140 "' EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. SIDE WALL HEIGHT 11.2" LEACHING AREA REQUIRED: (440) = 594.59 S.F. AEG/ E � 50.25 Cl 42" 50.75 42" OVERALL HEIGHT 16" •74 S4NITAW0, C1 4640 TRUEMAN BLVD DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) OVERALL WIDTH 34" ) MEDIUM SAND MEDIUM SANG HILLIARD, OHIO 43026 PRIMARY S.A.S. It o��oS 2.5Y 7/4 2.5Y 7/4 CAPACITY 13.6 CF MIZE* USE 4 ROWS OF 5 - 16" ADS BIODIFFUSER H-20 UNITS-NO STONE (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. AND EXTENDED 0.75 FT WITH CONTOURED WEDGE B R PERC ®48.42 PROPOSED SEPTIC SYSTEM SITE PLAN BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER)(BIODIFFUSERS) 20 UNITS x 6.25 LF x 4.70 SF/LF = 587.50 SF 42.25 138" 42.75 138" 1 109 SHOOT FLYING HILL ROAD, HYAN N I S, MA (BIODIFFUSERS) 4 UNITS x 0.75 LF x 4.70 SF/LF = 14.1 SF PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Mike Dedecko DESIGN FLOW PROVIDED: 0.74GPD/SF(601.6 SF) = 445.18 GPD > 440 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN DARRENM.MEYER,R.S. Eco-Tech Environmental NTS D.M.M. C eT • I, Darren M. Meyer, R.S., CSE• hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX 98f (508) 364-0894 DATE: CHECKED to conduct soil evaluations and that the above analysis has been performed by me consistent with the EASTSANDW/CH,MA02537 SHEET NO. requirements of 310 CMR 15.017. 1 further certify that 1 have passed the Soil Evol. Exam in October, 1999. 508-362-2922 1 1/03/09 D.M.M. 2 Of 2 REV15ION 1 I/09/2009-ADD SECOND I,000G 5EPTIC TANK ''t. tr£t-z'r' M'av ,e'�,, a?..�: ', L •a aK. ,' - ,z, ,c .4,. _ ^x. �s . x � _ b , i r a X kF 'h!e • - h i Pl P� tr114, to e w98 No wHT'Eg E.vcou1.v7-SE'E1> TE.S T 14 o L E E' ESU.. , TS TO l\,/A/ W)Q TER / Q VA / L iq 8 L E ivsP P,19 UL /a'I U p:R°R y /l/ A//-IU1-7 OUILLIAIG 5,ET,3f91 %?EQUIPEJ!-IE"7"S p,�'.G� PCJSE3J .EaT:),/`OCJM,�' D/2/ VE w�1Y Al/ O 7- T© L3 E -��..L�C (� "•�.D � • Cpl/E SE G./E ,�?�1QE SyS � EM U�/LESS • DES/GnJ FLOh.I 3 30, L D y N-2o z)E'61C J L011' rANG° . P,�oF?OS D � �cHi' zao ` SEPTie SySE M CoNsu T•/ O , ,% 9C ERC ©L /Oi`!` TEST' C:ON F`� ,�M T O /'�1 A'-S.S.. C t\/-V/� O 1�J M E N T�3 .C„'; • . C 0 D,E. - -L:) ��'�D J"Ul- Y /, /9 77 6A D �7-0,k/X/ - 2kES'IJLTS M/tiI /AJCN Bl� 'N5T' }8 4 E H Ems?L TfN fzEG,UL H T/ O/V5'. °` - ... . • S/LL �--LEV.}TO°*I3G -FT. 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