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HomeMy WebLinkAbout0563 STRAWBERRY HILL ROAD - Health (2) 5(03s1fo" Ui.0 2d _J 11 �Op THE Tp� Town of Barnstable Barnstable Regulatory Services Department ;edcaCffy ■ BARNSTABLE. ` "A 9.�bgq Public Health Division �� m ArE0 rKA�A 200 Main Street, Hyannis MA 02601 2007 f- • • 1 Office: 508-862-4644 Thomas F.Geiler >undwagter,Director FAX: 508-790-6304 `j Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 56-H Julyl2, 2011 Mr. Edward Sullivan 563 Strawberry Hill Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 563 Strawberry hill Rd, Hyannis, MA. was last inspected on 4/02/2011 by Michael Hudson certified septic inspector for the State of Massachusetts. According to the private septic system inspector, the system "Conditionally Passes" due to the following: • Outlet tee in septic tank needs to be repaired or replaced. • Outlet baffle cracked and needs replacing. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace.the septic system within the deadline period may result in future enforcement action PER ORDER OF THE B ARD OF HEALTH f T ean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc m �. � . UD Ln trt ru Ln •. m L� m Postage $ +� `/c/Gl J ' 0 � C3 Certifled Fee I R) C Return Receipt Fee 111 a (Endorsement Required) A e' 0 Restricted Delivery Fee s rl (Endorsement Required) co C3 Total Postage&Fees SL ..0 O Se T. n !ti Street,Apt.No.; z g r J ......._..r .. or PO BoxNo.� J _�o�[ - city crate,zrR+a � � !7 ,-;?ZU/ Certified Mail Provides:• A mailing receipt ,j(BsieAa li)aooa eunr loose uuod Sd d A unique identifier for your mailpiece • A record of delivery kept by the Postal Service for two years kkdortant Reminders: ' 91 Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. a Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. • For an additional fee,it Return Receipt may be requested to provide proof of, delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the, fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. to For an additional fee, delivery may be restricted to the addressee or addressee's authorized anent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-DeWery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle At the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it.when making an inquiry: internal access to delivery Information is not available on mail addressed to APOs and FPOs. SENDER: COMPLETE THIS SEC1,W-ON COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent 1 ■ Print your name and address on the reverse ❑Addressee 1 so that we can return the card to you. B. Received by(Printed Name) C. Date of-Delivery ■ Attach.this card to the back of the mailpiece, 1 or on the front if space permits. 1 D. Is delivery address different from item 1? ❑Yes I I.,Article Addressed to: If YES,enter delivery address below: ❑ No I I Mr. Edward Sullivan 1 563.Strawberry Hill Road .Hyannis, MA 02601 s. service Type 1 ❑Certified Mail ❑Express Mail 1 a ❑ Registered ❑ Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 1 4. Restricted Delivery?(Extra Fee) ❑Yes 1 2. Article Number. �- 7 0 0 6 0 810 0000 3525 5583 �m (Transfer from se vice label) PS Form 3811,February 2004 Domestic Return,Receipt 102595-02-M-1540;1 � A UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISP$ Permit No.0-10 t _ • Sender: Please print your name, address, and ZIP+4 in this box • I PUBLIC HEALTH DEPARTMENT ` TOWN OF BARNSTABLE j 200 MAIN STREET A HYANNIS, MA 02601 I I ( I I Town of Barnstable Barnstable P� AN- E, Regulatory Services Department � Of s;caDC IIARN3SABL 6 . ►,�� Public Health Division �ArfD MAI A 200 Main Street, Hyannis MA 02601 2007 f Office: 508-862-4644 Thomas F.GeilerLeach pit is onl�f )undwagter,Director FAX: 508-790-6304 3" ,zp Thomas A.McKean,CHO CERTIFIED MAIL# 7006 0810 0000 3525 .55+83 Julyl2, 2011 Mr. Edward Sullivan 563 Strawberry Hill Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at, 563 Strawberry hill Rd, Hyannis,MA, was last inspected on 4/02/2011 by Michael Hudson certified septic inspector for the State of Massachusetts. According to the private septic system inspector, the system "Conditionally Passes" due to the following: • Outlet tee in septic tank needs to be repaired or replaced. • Outlet baffle cracked and needs replacing. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system_ within the deadline period may result in future enforcement action PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures\1-I SAMPLE 60 Day Deadline.doc �dc�'��' l j �i � /U� � ��x��r ,.� ;�:� ��hy.,e* fib�§'� •�z��£� il �,, ,©WI n.l $ 2 Ln ru OFFICIAL Ln — . o �j Postage $ ` ��C�j p Certified Fee 0 t?ostmerk C3 Return Receipt Fee Here (Endorsement Required) E3 Restricted Delivery Fee a (Endorsement Required)co �SQS Total Postage&Fees $ 5;,JNi ..0 O Sent To O �� - ..........^ -- Street ApIF No.; or PO Box No. 0 3� Certified!Nail Provides: eaea)mou e-r'oose-OA Sd a A mailing receipt ..- • A unique identifier for your mailpiece tt A record of delivery kept by the Postal Service for two years Imldortent Reminders: a Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. a Certified Mail is not available for any class of international mail. 4 NO INSURANCE COVERAGE IS PROVIDED 'with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS9 postmark on your Certified Mail receipt;is required. •For an additional fee, delivery may be restricted to the addressee or addressee's authorized a ent.Advise the clerk or mark the mailpieoe with the endorsement"Restricted-Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. WPORTANT:Save Ibis receipt and present it.when making an inquiry. Internet access to delivery information is not available on trail addressed to AM and Ms. j t ..,. UNITED STATES POSTAL SERVICE _ - ► ' „� • Sender: Please print your name, address, and ZIFYi'h box •'°" M I PUBLIC HEALTH-DEPARTMENT V A TOWN OF BARNSTABLE ; 200 MAIN STREET I HYANNIS,MA 02601 - o �.:�...d�r. 1�I�dldtdi}�I�i7'd�lldl!!}lil�ll���i!l1��d1!l tlll�i.ld{t-�11.t.7Ct131 Fi�� SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sig r item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. •3. Re eived by( rint Na e) C. Date of Delivery ■ Attach this card to the back of the mailpiece, � J�I 1 or on the front if space permits. / t D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No Nli=. Edward Sullivan 1.563 Strawberry Road Centerville, MA 02632 s. service Type i ❑Certified Mail ❑Express Mail ❑ Registered ❑ Return Receipt for Merchandise `__--- -- ---- ❑ Insured Mail ❑C.O.D. I 4. Restricted Delivery?(Extra.Fee) ❑Yes 2. Article Number (Transfer from service iabeij I j j j 1 j-j-7k9 0 61 0 810 2 ;5 6 20 -turn Receipt 1025e5-02-M-1540 'I Commonwealth of Massachusetts Title 5 Official Inspection form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 563 Strawberry Hill Rd Property Address Ed Sullivan Owner. Owner's Name information is Centerville MA 02632 04/02/11 required for every page. Cityrrown State Zip Code Date of Inspection / Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Im outf A.When A General Information fillingng out forms i on the computer, use only the tab 1. Inspector: key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Envrinmental Services V Company Name 31 Midway Dr Company Address Centerville MA 02632 City/Town State Zip Code 508-367-5669 DEP SI#4254 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address pe and tha_t"the information reported below is true, accurate and complete as of the time of the insction. The inspection was performed based on my training and experience in the proper function and,rrjaintenance-of orFae sewage disposal systems. I am a DEP approved system inspector pursuant`to Section 1'S.340* Title 5(310 CMR 15.000).The system: -- - ❑ Passes ® Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 0- > r1 06/20/11 Inspector'srIgnafufa 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. f f � vV � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Di sal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Ownees Name information is required for every Centerville MA 02632 04/02/11 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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. 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. L ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M °'< 563 Strawberry Hill Rd Property Address Ed Sullivan Owner owner's Name information is required for every Centerville MA 02632 04/02/11 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): j ® broken pipe(s)are replaced ❑ Y Z N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below) t ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ,Outlet tee in septic tank needs to be repaired or replaced. ❑ 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: El 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 CHAR 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•11J10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every. Centerville MA 02632 04/02/11 page. Citylrown 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. There are 2 septic systems. In the front a 1000 gallon septic tank, d-box and leach pit and in the back two 1000 gallon cesspools one acting as a septic tank overflowing to the other. The SAS in the front system is in very good condition and passes. The outlet tee needs to be repaired on the tank. The cesspool system in the back is in hydraulic failure. Recommend plumbing all sewage and laundry to iron system. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes' No ® ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityfrown 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. El ® 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 wlell. El ® 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.] l The system is a cesspool serving a facility with a design flow of 2000gpd- #�#E] ® 10,000gpd. I ® ❑ 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. N� 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 j questions in Section D. i 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 El Elthe 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. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 j Commonwealth of Massachusetts lugTitle 5 Official Inspection . Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown State Zip Code Date of Inspection C. Checklist 4 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with ' information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is Centerville MA 02632 04/02/11 required for every page. Citylrown state Zip Code Date of Inspection D. System Information Description: ' Number of current residents: unknown 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 ears usage d 2009-337 GPD 9 ( Y 9 (gP )k 2010-342;GPD Detail: Sump pump? ❑ Yes ❑ No occLast date of occupancy: Date d Date CommerciaUlndustrial 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•11110 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts ME. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cltyrrown 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: Water Pollution Control Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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•11/10 r Title 5 Official Inspection Form:Subsurface Sewage Dispose)System.•Page 8 of 17 Commonwealth of Massachusetts : W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner owners Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown State Zip Code bate of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Estimated 35 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 301' Depth below grade: feet Material of construction:' ❑ cast iron: 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1211 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 4'10"Wx8'6"Lx5'8"H- 1000 gallon Sludge depth: 4'10"(2"thickness) t5ins•11/10 T'Ne 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is Centerville MA 02632 04/02/11 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1"or less 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? measured sludge probe, tape, floodlight, mirror Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping 1x every 3 years, inlet baffle in fair condition,,outlet baffle cracked and needs replacing,"liquid levels normal in relation to outlets, tank not leaking at time of inspection. 4 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:, Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 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 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even w/outlet 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.): Level, no signs of solids or leaks 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6' Radius w/ stone around ❑ leaching chambers number:. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number. (1)6' radius ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): , 6'radius overflow cesspool in rear and 6'radius leachpit in front, loamy to med sands, SAS in rear, hydraulic failure, liquid level above inlet invert. SAS in front has 6" liquid level and 36+ inches-of clean sidewall around perimter of pit. No signs of failurein the fron system. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration (1)serving as septic tank Depth—top of liquid to inlet invert 2' Depth of solids layer Depth of scum layer 1'+ Dimensions of cesspool 6' RADIUS Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts : W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown 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 t5ins•11/10 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 563 Strawberry Hill Rd Property Address Ed Sullivan Owner owner's Name information is required for every Centerville MA 02632 04/02/11 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope L 3 ° ® Surface water *3 ® Check cellar ►J A- Z Shallow wells N 1A' Estimated depth to high ground water: 22 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) i ® Checked with local Board of Health-explain: Reviewed prior inspection ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS Topo and water resource maps. You must describe how you established the high ground water elevation: Reviewed prior inspection by James M. Ford dated 11/02/02 F - Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Strawberry Hill Rd Property Address Ed Sullivan Owner Owner's Name information is required for every Centerville MA 02632 04/02/11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Vnspection Summary:A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)completed Gf"s-ystem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins•11/10 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 17 of 17 9 Ys -.• Page l0 of 11 : . � r<: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 4c SYSTEM INFORMATION (continued) Property Address 563 Strawberry Hill Road(Front System). Centerville,MA ( Owner Elizabeth Russell Date of Inspection: November 2, 2002` Map:249 Parcel:013 Lot.6 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. 03. Z . �- _ ;3 3 O 10 Page 10 of 11 OFFICIAL INSPECTION FORM =NOT €}It VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPQSA SYSTEM INSPECTION FORM - SYSTEM INFOR'4IATION (continued) Property Address: 563 Strawberry Hill:Road Backs ernl Centerville.'LIMA Owner: Elizabeth Russell Date of Inspection: November 2'2002:. _. Map:249 Parcel:013 Lot: 6 SKETCH OF SEWAGE DISPOSAL SYSTEM ... `. Provide a sketch of the sewage disposal system including ties to at.feast two permanent reference landmarks or :benchmarks. Locate all wells within 100 feet. Locate where pube water supply enters the building. y i A OL q. ;I 10