HomeMy WebLinkAbout1160 PHINNEY'S LANE UNIT BLDG 2 UNIT C - Health 1160 PHINNEY'S LANE
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c Commonwealth of Massachusetts a _0 9'?�
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
1160 Phinney's Lane Building#2, Centerville, MA
Property Address p
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019 Y,
•�'
page. City/Town State Zip Code Date of Inspection h,»
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 3 Qy g
� /
on the computer,
use only the tab Joseph M Martins
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
� Company Address
South Dennis MA 02660
City/Town State Zip Code
r 508-385-5891 SI 147
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
7/12/2019
Insp or'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.
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SOME SIGNS OF STRESSING IN LEACH PITS .AT THIS TIME NO FAILURE CRITERIA ARE
TRIGGERED. RECOMMEND REDUCE OUTLET TEE LEG LENGTH. INSTALL GAS BAFFLE AND
MONITOR PIT LEVELS.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ -N ❑ ND(Explain below):
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Boar/Healtha if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the
to broken or obstructed pipe(s)or due to a broken, settled or uneven dis ' ution 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 ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required p/ved
han 4 times a year due to broken or obstructed pipe(s).The
system will pass inspeproval of the Board of Health):
❑ broken pipe(s ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of H/annh
❑ Conditions exist which require further evaluation of Health ' order to determine if
the system is failing to protect public health, safeironme
/'
a. System will pass unless Board of Health d a ordance with 310 CMR
15.303(1)(b)that the system is not functioning hich will protect public health,
safety and the environment:
t5insp.doc•rev.7262018 Title 5 official Inurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetla or a salt marsh
b. System will fail unless the Board of Health (and Public Water upplier, if any)
determines that the system is functioning in a manner that pr ects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system AS)and the SAS is within
100 feet of a surface water supply or tributary to a surface ater supply.
❑ The system has a septic tank and SAS and the SAS ' within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the S is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and a 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 a ysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and a pres ce of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, prov' ed that n oth ilure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure j
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/public
system must se e a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yto each of t following, in addition to the
questions in Section CA.
Yes No -the system iswithin 400 ace drinking water supply
❑ ❑ the system is within 200ibutary to a surface drinking water supply
❑ ❑ the system is located insensitive area(Interim Wellhead Protection
Area—IWPA)or a map of a public water supply well
t5insp,doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
NU
® ❑ Were all system components C uding 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)]
I
t5insp.doc-rev.7/M018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
Description:
2000 GALLON SEPTIC TANK, DISTRIBUTION BOX, AND 2 6' LEACH PITS W 4'
OF STONE
Number of current residents: VARIES
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 579/2=290
9 ( Y 9 (9P ))�
Detail:
2018: 199,000 G ; 2017: 224,00 G FOR BLDGS 1&2
Sump pump? ® Yes ❑ No
Last date of occupancy: Date 12019
t5insp.doc•rev.MW2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Citylrown 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): Ga ns per day(gpd)
Basis of design flow(seats/persons/sq.ft., a ):
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 itle 5 system? ❑ Yes ❑ No
Water meter readings, if available
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: PUMPED IN 2013 PER MANAGER. TANK PUMPED
AFTER INSPECTION
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
. gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Flame
information is required for every Centerville MA 02632 6/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System.
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool -
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
39 YEARS. INSTALLED 1983 PER TOWN RECORDS.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain): NOT VIEWED
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2.5
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: APP 12 X6X5 2000 G
Sludge depth: 7 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 11 INCHES
Scum thickness 2 INCHES
Distance from top of scum to top of outlet tee or baffle 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle 30 INCHES
How were dimensions determined? CORETAKER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS PVC INLET TEE. HAS PVC OUTLET TEE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO
EVIDENCE OF LEAKAGE. RECOMMEND REDUCE TEE LEG LENGTH TO 14"AND INSTALL GAS
BAFFLE ON OUTLET TEE.
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 0202 6/12/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet/ae
Distance from bottom of scum to bottom ofleDate of last pumping: Date
Comments (on pumping recommendationtee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evietc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass/E01 hylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ NXworkiorderr:
Alarm level: Alarm in ❑ Yes ❑ No
Date of last pumping: Z
Comments (condition of alarm and float switch ,
*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 AT INVERTS
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.):
DBOX IS IN GOOD CONDTION. EVEN FLOW DISTRIBUTION.
t5insp.doo•rev.7r2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
10. Pump Chamber(locate on site plan):
Pumps in working order: /a7nd
es ❑ No*
Alarms in working order: es ❑ No*
Comments (note condition of pump chamber, condition of nances, etc.):
* If pumps or alarms are not in workin rder, system is a conditional pass.
11. Soil Absorption System(SAS) cate on site plan, excavation not required):
If SAS not located, explain w
Type:
® leaching pits number: 2 6'X6'W 4'
STONE
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
t5insp.doc-rev.7/28/2M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/12/2019
required for every
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.):
RIGHT SIDE PIT: LIQUID LEVEL IS 1.0'. MODERATE STAIN LINE WITHIN 6'OF PIPE. SOME
LEACHING OPENINGS SEMI PLUGGED. SIGN OF PREVIOUS STRESSING.
REAR PIT: LIQUID LEVEL IS 2.6'. STAIN LINE WITHIN 6"OF PIPE. OBSERVED SOME SCUM
ON PIPE . SIGNS OF PREVIOUS STRESSING. SOME LEACH OPENINGS SEMI PLUGGED.
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site pl
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 inflo ❑ Yes ❑ No
Comments(note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
.. 4;
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i
Commonwealth of Massachusetts
�Uvi
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of by raulic failu , level of ponding, condition of vegetation,
etc.):
/zu
t5insp.doc•rev.726/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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C Q CAR
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is
required for every Centerville MA 02632 6/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 32
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:
GOOGLE MAPS, CCC GROUNDWATER CONTOUR, FRIMPTER
You must describe how you established the high ground water elevation:
SITE IS 74'ASL WITH A GROUNDWATER CONTOUR OF 32'ASL. MAX RISE IS 8'. GRADE TO
SAS BOTTOM IS 10:5' SEPARATION MATH: 74-(32+8+10.5)=21.5
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form-.Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#2, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/12/2019
page. Cityrrown 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
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
I
Commonwealth of Massachusetts a33 -089-00.6
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
f i
r.;
1160 Phinney's Lane Building#3, Centerville, MA I
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is ell
required for every Centerville f�(,�, MA 02632 6/14/2019 ,
page. Cityrrown State Zip Code Date of Inspection .
Inspection results must be submitted on this form. Inspection forms may not be alteredin any
way.Please see completeness checklist at the end of the form.
Important:out forms A. Inspector Information v1, i s qq(v
filling out forms
on the computer,
use only the tab Joseph M Martins
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
r� Company Address
South Dennis MA 02660
Cityrrown State Zip Code
508-385-5891 SI 147
Telephone Number License Number
B. Certification
I certify that: 1 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
7/12/2019
Inspeo6es 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.
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass°sec/neede
replaced or repaired. The system, upon completion of the replacement or r air, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the foll Ing statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic to (whether "etal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration r tank (lure is i inent. System will pass
inspection if the existing tank is replaced with a comp ng tic tan s approved by the Board of
Health.
*A metal septic tank will pass inspection if it is struc o r Ily sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 2 s is available.
❑ Y ❑ N ❑ ND(Explain low):
t5insp.cloc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board f Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water lev in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or une n distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ ND(Explain below):
❑ obstruction is removed ❑ Y N.. ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ N ❑ ND(Explain below):
El The system required pumping more t n 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with a proval of the Board of Health):
❑ broken pipe(s)are replac ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Re uired by the Board of Health:
El Conditions exist whi require further evaluation by the Board of Health in order to determine if
the system is failin 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:
I
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
z Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
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 borde/hanee
etated wetland or a salt arsh
b. System will fail unless the Board of Health(an Water Supplier, ' any)
determines that the system is functioning in a maat protects the ublic health,
Y 9P
safety and environment:
n it absorptionsystemSAS an the SAS is within
❑ The system has a septic tank and so abso p ( )
100 feet of a surface water supply or tributary to a suter sup y.
❑ The system has a septic tank and SAS and the Sithin one 1 of a public water
supply.
❑ The system has a septic tank and SAS and the Si in 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the Sss 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, e d at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the pres a of mmonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other fa' re eria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine w twill be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system mu se e a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to c f the (lowing, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 fe f a surface drinking water supply
❑ ❑ the system is within 2 feet of a tributary to a surface drinking water supply
❑ ❑ the system is loc d in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
-F 1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
I
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
Description:
2000 GALLON AND 1000 GALLLON SEPTIC TANK IN SERIES, DBOX AND INFILTRATORS
WITH STONE.
Number of current residents: VARIES
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 ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
645/2= 323
Detail:
2018: 254,000 G ; 2017: 216,900 G
Sump pump? ❑ Yes ® No
Last date of occupancy: Date Date 019
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityfrown 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 presen . ❑ Yes ❑ No
Non-sanitary waste discharged t itl system? ❑ Yes ❑ No
Water meter readings, if ava' ble:
Last date of occupancy/ e: Date
Other(describe I ):
3. Pumping Records:
Source of information: PUMPED IN 2013 PER MANAGER
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 3000
gallons
How was quantity pumped determined?
Reason for pumping: PER MANAGER
t5insp.doc•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160
PhinneY's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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:
2K TANK IS 36 YEARS OLD. 1000 G TANK AND DBOX AND SAS POST 1995 NO INFO
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: NOT VIEWED
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.):
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3.5
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: APP 12X6X5, 2K G; 8.5X6X5 1 KG
Sludge depth: 9 INCHES 8 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 9 INCHES 9 INCHES
Scum thickness 3 INCHES 0 INCH
Distance from top of scum to top of outlet tee or baffle 6 INCHES 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle BOTH 30" LEG LENGTH
How were dimensions determined? CORETAKER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
2K TANK: HAS 2 PVC INLET TEES, ONE PVC OUTLET TEE. LEG LENGTH 30" RECOMMEND
SHORTENING TO CODE AT 14". INSTALLED NEW RISER TO REPLACE BROKEN RISER AT
INLET END OF TANK. 1 K TANK: HAS PVC TEE AND PVC OUTLET TEE. LEG LENGTH IS 30"
RECOMMEND SHORTENING TO 14". BOTH LIQUID LEVELS ARE 4*'AT OUTLET INVERT.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/14/2019
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
/N/ADepth below grade:Material of construction:
❑ concrete ❑ metal ethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of utlet tee or baffle
Distance from bottom of scum bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumpin to to
inlet and outlet tee or baffle condition, structural in rity,
liquid levels as relate o outlet invert, evidence of leakage, etc.):
z A
8. Tight or Holding Tank(tank must be pumped at time of inspection)(local on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass polyethylene Elother(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Ye o
Alarm level: V-):
i orking order: ❑ Yes ❑ No
Date of last pumping:
Comments(condition of alarm and float swit
"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 AT INVERTS
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.):
VIEWED W CAMERA. BOX IS IN MINT CONDITION. NO SOLIDS CARRYOVER.
t5insp.doc-rev.MAJ2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: /and
Yes ❑ No"
Alarms in working order: Yes ❑ No*
Comments(note condition of pump chamber, condition enances, etc.):
*If pumps or alarms are not i/�id system is a conditional pass.
11. Soil Absorption System(SAte plan, excavation not required):
If SAS not located, explain w
Type:
❑ leaching pits number:
® leaching chambers number: INFILTRATORS
QTYUNKNOWN
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c10 Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
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.):
EXAMINED PORTION OF SOIL AND STONE ADJACENT TO INFILTRATOR. BOTH SAND AND
STONE ARE CLEAN; GRADE TO SAS BOTTOM IS<6'
12. Cesspools(cesspool must be pumped as part of inspection)(locate on site an):
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 hydra c failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc•rev.M62018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydr is failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/28/2018 Title 5 Official hispection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160
PhinneY's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A-; RIG•i{T Slog
12
0 `0
Q
"
.. o
r , . verb'
�2-3�•Sf g2--��o.S'
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 34
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:
GOOGLE MAPS, GROUNDWATER CONTOUR BY CCC, FRIMPTER
You must describe how you established the high ground water elevation:
SITE IS 74'ASL W A GROUNDWATER CONTOUR OF 32'AND A MAX RISE OF 8' . GRADE TO
SAS BOTTOM IS<=6'. SEPARATION MATH: 74-(32+8=6)=281.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7126/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#3, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown 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
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
a�a- 089- 004-
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
F�
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46 ??
Owner Owner's Name
information is Centerville MA 02632 6/14/2019
required for every
page. Cityrrown State Zip Code Date of Inspection
u;
4.
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Joseph M Martins
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
tab Company Address
South Dennis MA 02660
Cityrrown State Zip Code
508-385-5891 S1 147
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 16.000); 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
7/12/2019
Ins tor'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.
t5insp.doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional ss"section need to be
replaced or repaired. The system, upon completion of the repla ent or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND r the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or t septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltr on or tank failure is imminent System will pass
inspection if the existing tank is replaced with complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspec' n if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tan,
an s less than 20 years old is available.
❑ Y ❑ N ND(Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in t distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven ' ribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ ❑ ND(Explain below):
❑ obstruction is removed ❑ Y N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ N ❑ ND(Explain below):
❑ The system re/pumpiore than 4 times a year due to broken or obstructed pipe(s). Thesystem will paith approval of the Board of Health):
❑ brokeced ❑ Y ❑ N ❑ ND(Explain below):obstru ❑ Y ❑ N ❑ ND(Explain bel
z W/
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board Health in order to determine if
the system is failing to protect public health, safety or the en ' nment.
a. System will pass unless Board of Health determin in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a anner which will protect public health,
safety and the environment:
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary(cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that /aater
e public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(S SAS is withi
100 feet of a surface water supply or tributary to a surface water
❑ The system has a septic tank and SAS and the SAS is withiof a pu c water
supply.
❑ The system has a septic tank and SAS and the SAS is withirivate watersupply well.
❑ The system has a septic tank and SAS and the SAS is less t 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 a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of a onia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure c ' ria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must se a facili ith a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each o h ollowin ' addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of urface drinking water supply
❑ ❑ the system is within 200 f of a tributary to a surface drinking water supply
❑ ❑ the system is located ' a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a apped Zone 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 5 of 18
I
C\, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.70=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owners Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 8 Number of bedrooms (actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
Description:
2000 G SEPTIC TANK,DISTRIBUTIN BOX AND 2 6'X6' PITS W 4' STONE
Number of current residents: VARIES
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 645/2=323
9 ( Y 9 (gPd))�
Detail:
2018: 254,000 G 2017: 216,900 G WATER RECORDS FOR BUILDINGS 3 AND 4
Sump pump? ❑ Yes ® No
Last date of occupancy: 6/14/2019
Date
t5insp.doc•rev.726/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
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 ndr 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 sy e ? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: COMPLEX LAST PUMPED IN 2013 PER MANAGER
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 2000
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/rows State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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:
36 YEARS. INSTALLED 1983 PER HEALTH DEPT.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: NOT VIEWED
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.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3
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: APP 12 X6X5 2000 G
Sludge depth: 7 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 17 INCHES
Scum thickness 2 INCHES
Distance from top of scum to top of outlet tee or baffle 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle 24 INCHES
How were dimensions determined? CORETAKER
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS PVC INLET TEE AND PVC OUTLET TEE. LIQUID LEVEL IS 48"
AT OUTLET INVERT . NO EVIDENCE OF LEAKAGE.
t5insp.doc•rev.7/2W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethyl ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or e
Distance from bottom of scum to bottom of tlet tee or baffle
Date of last pumping: Date
Comments(on pumping recomme ations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet i ert, evidence of leakage, etc.):
A z a
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate ite plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass/[0--] hylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.dm-rev.7/26=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/14/2019
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: ' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of aXndwitches, etc.):
*Attac 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 NOT FOUND
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.):
COULD NOT LOCATE DBOX EITHER TO DEPTH >4'OR BAD AS BUILT.
t5insp.doc•rev.7/2612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
f
Commonwealth of Massachusetts
'1910
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/14/2019
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: yYes ❑ No*
Comments(note condition of pump chamber, condition of pumps and aes, etc.):
* If pumps or alarms are not in working order, syst is a nditional pass.
11. Soil Absorption System(SAS) (locate on sit plan, is
not required):
If SAS not located, explain why:
Type:
�
® leaching pits number: 2 6'X6'W 4'STONE
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/262018 Tide 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owners Flame
information is required for every Centerville MA 02632 6/14/2019
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PIT CLOSEST TO ROAD: LISTED COMPONENT#4 ON SKETCH: LIQUID LEVEL AND STAIN i
LINE AT 3.4'ABOVE PIT BOTTOM. GRADE TO SAS BOTTOM IS 11'. NO EVIDENCE OF
FAILURE. PIT IN REAR: LISTED AS COMPONENT#5 ON SKKTCH. LIQUID LEVEL OF 2.4'W
STAIN LINE AT 3'ABOVE PIT BOTTOM. GRADE TO SAS BOTTOM IS 12'.
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 draulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
lq�--1-- —
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure eve of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
L
t�Sht `
A
to
N•F .
91 =(42t
A3=S3,5` .�3 =y5' �Ae� �2vHo� InS,p�cfld►-.
A lost (3L(-
6S;::3 3 '
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�
Title 5 Official Inspection Form
. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is' Centerville MA 02632 6/14/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cbnt.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 34
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:
GOOGLE MAPS, CCC GROUNDWATER CONTOUR, FRIMPTER
You must describe how you established the high ground water elevation:
SITE IS 74'ASL WITH A GROUNDWATER CONTOUR OF 32'ASL. MAX RISE IS 8'. GRADE TO
SAS BOTTOM IS 12'. SEPARATION MATH: 74-(32+8+12)=22'.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7
1160 Phinney's Lane Building#4, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/14/2019
page. Citylrown 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
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
s TOWN OF BARNSTABLE
BOARD OF HEALTH
] ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date 1b 1 Time: In Out
Owner Tenant Tenant ( 2/zla�1 (�1W1A
Address (70 (1 lIJ Address l / r-� t4hie.
W- EA F4 476 U, Y11 1,)4 A 4
Compliance Remarks or
Regulation# Yes NO Reco m n lations
2. Kitchen Facilities
3. Bathroom Facilities .. -
4. Water Supply JIp ����5
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal ✓ f
16. Sewage Disposal
17.Temporary Housing
18. Driveway Width
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allow )
Number of Persons Allowed (max) "
Person(s) Interviewed ��� (� \ Inspector
If Public Building such as Store or Hotel/Motel specify here
a 00p,AM
aAMjr-jLUD o � �
M
�P-
,, F ICI
cO Certified Mail Fee
Er $
_-r Extra Services&Fees(check pox;add fee as appropriate)
rq ❑Retum Receipt(hardoopy) $
I= ❑Returr Receipt(electrgnlc)�`$ .Postmark
0 ❑Certified Ma1l:Re8ictedDelivery _$ HEr6
0 ❑A�ullttSignatureRequired etr 'z$
[jAdult Signature Restricted de'l v.ry$l-'�-\
M is d
IM1 o N,`
ui ARB?ORiTERRACE CONDOMINIUMS
i QQ oc/o MIKE DONOVAN
� ,r. = a PO1BOX 46
C3 S C- TERVILLE, MA 02632
4�
��
Certifiied Mail setyice'provides the following benefits:
i A'receipt(this'portion of the Certified Mail'latiel). for an electronic return receipt,see a retail
•A unique identifier for Your mailpiece. associate for assistance.To receive a duplicate
■Electronl16enfication of delivery or attempted return receipt for no additional fee,present this L
delivery. �, USPS®-postmarked Certified Mail receipt to the ,
■A record of delivery(Including the recipients retail associate. i
signature)that is retained by the Postal Service- Restricted delivery service,which provides _p
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent
Important Reminders: Adult signature service,which requires the Cr
■You may purchase Certified Mali service with signee to be at least 21 years of age(not --a
First-Class Mail®,First-Class Package Service®, available at retail). M
or Priority Mail®service. Adult signature restricted delivery service,which
11 Certified Mail service is notavailable for requires the signee to be at least 21 years of age I
International mail. and provides delivery to the addressee specified]
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agenta
with Certified-Mail service.However,the purchase (not available at retail). tl
of Certified Mail service does not change the •To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a'.
certain Priority Mail items. USPS postmark.If you would like a postmark on rfi
•For an additional fee,and with a proper this Certified Mail receipt,please present your -,
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for F
the following services: postmarkirig.If you don't need a postmark on this
Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portiontj
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply F—I
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. M
electronic version.Fora hardcopy return receipt, 1y
complete PS Form 3811,Domestic Return
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
Ps Form 3800,April 2015(Reverse)PSN 7530-02-000-9047
ME
■ Complete It0 Agent
em� ty° 3. 7BRec7eivd
■ Print yc�tir na e a dress on the reverse ❑Addressee
so that>vie can re# .the card to you. 7
■ Attach this card to the back of the mailpiece, Prinp6o-�
Name) C. Da e,oiDelivery
or on the front if space permits. �c�, � v �j(
dress different from item 1? ❑ es
(delivery address below ❑No
ARBOR TERRACE CONDOMINIUMS
c/o MIKE DONOVAN
PO BOX 46
CENTERVILLE, MA 02632
II I III II I II I�I I I IIII I I I III II II I (I III III Adult
Signature
ig Type ❑Priority Mail ailTM s8
❑Adult Signature ❑Registered MaiIT"'
❑Adult Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 4798 8344 8736 12 ertified Mail® Delivery;.
ertified Mail Restricted Delivery Return Receipt
❑Collect on Delivery AMerchandise
p�nt�m_nl.rr Tr�nefar_frnm_eemlca hhan _ Collect on.Delivery Restricted Delivery ❑Signature Cortflrmation*M
l El Signature Confirmation
7 01'5 17 3 0' O D 01 4'9 8`7' 9 7 3 6 ! I Restricted Delivery Restricted Delivery
a._.I
', PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
USPS TRACKING#
First-Class Mail
Postage&Fees Paid
LL USPS
Permit No.G-10
9590 9402f*49418344 8736 12
I
United States •Sender:Please print your name,address,and ZIP+4®in this box*
Postal Service j
Town of Barnstable
(�O) Health Division
200 Main Street
Hyannis, MA 02601
I
I I I
ii:jjl?illllll°111it' 1i1'irfill li-ii.,ifl lit iii{1i!ill 11-h,,ii,iiiii
Town of Barnstable Barnstable
Inspectional Services Department AS-Amwica
BAEtNSTABLE;.
M.q� 6 9. ,e� Public Health Division
ArfiD �s 200 Main Street, Hyannis MA 02601 2007
l
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4987 9736
July 9, 2019
ARBOR TERRACE CONDOMINIUMS c/o MIKE DONOVAN
PO BOX 46
CENTERVILLE, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 1160 Phinney's Lane, Building#1, Hyannis, MA was
inspected on 06/05/2019 by Joseph M Martins, certified Title V Septic Inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under_the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
I
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 will result in future
enforcement action.
f
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\1160 Phinneys Lane Bull&,- I
Centerville.doc
r
Town of Barnstable
BARNSTABM
9w b 9 A Inspectional Services Department
ArED MA'S
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above-outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of aof a driveway due to H-10 components, etc)
Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
{ Commonwealth of Massachusetts ��3" 9� 60
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f
1160 Phinney's Lane Building#1, Centerville, MA r
Property Address t`
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46 `
Owner owner's Name
information is ?.f
required for every Centerville ✓ MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
t i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:out forms A. Inspector Information 61 � 39(
filling out forms
on the computer,
use only the tab Joseph M Martins
key to move your Name of Inspector
cursor-do not Accu Sepcheck
use the return Company Name
key.
17 Northside Drive
Company Address
South Dennis MA 02660
City/Town State Zip Code
508-385-5891 SI 147
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 CHAR 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. 'Is
6/25/2019
17&WPs SignYA V 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.
t5insp.doc•rev.7126=18 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all,of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluate are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection Ar
C. Inspection Summary (cont.)
2) System Conditionally Passes(cunt.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of alth approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water I el in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or u ven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ ❑ N ❑ ND(Explain below):
❑ obstruction is removed Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND(Explain below):
A /4
❑ The system require umping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass i pection if(with approval of the Board of Health):
❑ broken ipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ ob ction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) rther Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
j the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
W- 1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a alt marsh
b. System will fail unless the Board of Health(and Public Water Sup •er,if any)
determines that the system is functioning in a manner that protec a public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SA and the SAS is within
100 feet of a surface water supply or tributary to a surface wat supply.
❑ The system has a septic tank and SAS and the SAS is in a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SA is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and th AS 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 an sis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and t presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no ther failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/5/2019
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
® ElThe system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a fa 'lity with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or" o" each of wing, in addition to the
questions in Section CA.
Yes No
❑ ❑ the sZwithnin et of a surface drinking water supply
❑ ❑ the s feet of a tributary to a surface drinking water supply
❑ ❑ the s a nitrogen sensitive area(Interim Wellhead Protection
Areaped Zone 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/5/2019
required for every
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of br k out?
® ❑ Were all system components, I the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc-rev.7/M018 Us 6 Offidal Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual): 8
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880
Description:
2000 GALLON SEPTIC TANK, DISTRIBUTION BOX, AND 2 6'X5' LEACH PITS W STONE
Number of current residents: VARIES
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 579
9 ( Y 9 (gP ))�
Detail:
2018: 224,000 G ; 2017: 199.000 G THIS WATER USAGE IS FOR TOTALED BY WTER
DEPT FOR BUILDINGS 1 AND BUILDING 2
Sump pump? ❑ Yes ® No
Last date of occupancy: PRESENTLYDate
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd>
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: 0 //,
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: COMPLEX PUMPED IN 2013. THIS TANK AND
LEACH PITS PUMPED AFTER INSP. PER BHD.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is Centerville MA 02632 6/5/2019
required for every
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 j
❑ 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:
36 YEARS. INSTALLED 1983 PER TOWN RECORDS
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron ❑40 PVC ❑other(explain): NOT VIEWED
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
I
t5insp.doc•rev.7/AM18 Title 5 Offidal tnspeWon Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2teat
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: APP 12 X6X5 2000 G
Sludge depth: 7 INCHES
Distance from top of sludge to bottom of outlet tee or baffle 23 INCHES
Scum thickness 6 INCHES
Distance from top of scum to top of outlet tee or baffle 6 INCHES
Distance from bottom of scum to bottom of outlet tee or baffle 19 INCHES
How were dimensions determined? CORETAKER
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
HAS PVC INLET TEE AND PVC OUTLET TEE. LIQUID LEVEL IS 48"AT OUTLET INVERT. NO
EVIDENCE OF LEAKAGE.
I
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: N/A
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 ba
Date of last pumping:
Date
Comments(on pumping recommendations, inlet d outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidenc of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped a/inspectiopno) Ite plan):
Depth below grade:Material of construction:
❑concrete ❑ metal ❑fib ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 official Inspedion Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Ins ction
D. System Information (cont.)
8. Tight or Holding Tank(cunt.)
Alarm present: ❑ Ye ❑ No
Alarm level: rm in working orde/ ❑ Yes ❑ No
Date of last pumping: pate
Comments(condition of alarm and float swi e , e c. .
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert AT INVERTS
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.):
DBOX HAS ONE PIPE IN AND TWO PIPES OUTS. FLOW DISTRIBUTION IS EVEN.
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order. ❑ Ye ❑ No*
Alarms in working order: Yes ❑ No*
Comments (note condition of pump chamber, condition of pump nd appurtenances, etc.):
*If pumps or alarms are not in wo ing order, system is a conditional pass.
11. Soil Absorption System(S ) (locate on site plan, excavation not required):
If SAS not located, expl ' why:
Type:
® leaching pits number: 2 6'X5' DIAM.
PITS W STNE
❑ leaching chambers number:
❑ leaching galleries number
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sawage Disposal System-Page 13 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
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.):
SEE SKETCH: PITS HAVE AN EFFECTIVE DEPTH OF 60". ONE PIT HAS LIQUID LEVEL OVER
INLET PIPE WITH A LIQUID LEVEL OF 60"WITH A STAIN LINE 6"HIGHER. ONE PIT HAS A
LIQUID LEVEL OF OF 55.5"WITH A STAIN LINE 1"ABOVE. THESE HIGH LEVELS ARE A
FAILURE CRITERIA. BOTH LEACH PITS WERE PUMPED AFTER INSPECTION.
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, gns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doe•rev.7/28/2018 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System-Page 14 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. CitylTown State Zip Code ate of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs /hraulic;failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/28/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 18
c, Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I 1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
NV -^
2ts4j- s I E
�— A 8
a
O O
I
3
• S
0 O ' ag-jil.0 Lea
4 14allu
D SIPL CES o�� in/tT`pipe
Ai = 81= 43 ' IhIZI plpG
Aa.= «` 6a,S,9 .5`
A-3 = 3Lt' 83= 4a'
AK z 39 '
AS-47' 65,2r7'
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 33
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:
GOOGLE MAPS. CCC GROUNDWATER CONTOUR MAPS. FRIMPTER
You must describe how you established the high ground water elevation:
SITE IS 74'ASL WITH A GROUNDWATER CONTOUR OF 32'ASL. MAX RISE IS 8' . GRADE TO
SAS BOTTOM IS 10.5'. SEPARATION MATH: 74-(32+8+10.5)=21.5'
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of IS
V ' 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1160 Phinney's Lane Building#1, Centerville, MA
Property Address
Arbor Terrace Condominiums c/o Mike Donovan PO Box 46
Owner Owner's Name
information is required for every Centerville MA 02632 6/5/2019
page. Cityrrown 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
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18
YOU WISH TO OPEN A BUSINESS?
For Your information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
.�,:r r.,In.yY.tf I)•.L M/�'Fr9r:Pv
DATE: - 1.5 Fill in please: -
�Ik;& f:?li.�IvcibT.'ufVl.•FK.�J'I:T!�,'�l`rl�1ni''.��I `I. '�
fi=';r:�.tir�;•=;;a° ��G„�1y_ �; APPLICANT'S YOUR NAME/S: ���1�� ('+•��v�'
-,.' �C, ,note .n�'C �3
ift:Fl: BUSINESS YOUR HOME ADDRESS:
I f G �" Y`S �.. ✓4Q �C_ �• c'v�Ile.i /�. �
i Glie T' '•I'll 1 �i rr
�,F;% r`"��' �I � !d •rn.sir`<�
3G7-?"(`t3
TELEPHONE # Home Telephone Number
C� /^f� . Gt1�✓�
NAME OF CORPORATION: �w
NAME OF NEW BUSINESS e r 5 TYPE OF BUSINESS P
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS n �L IS MAP/PARCEL NUMBER Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable.. This form is intended to assist you in obtaining the information you-may need. You MUST .GO TO 200 Main St. - (corner of Yarmouth
Rol. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM SIO ER'S OFFICE
This individu I h e nrinf of n permit requirements that pertain to this type of business.
MUST COMPLY WITH HOME OCCUPATION
Au on Sig_Wt6i e** RULES AND REGULATfONS. FAILURE TO
O MENTS _LA GQMIR1 !4 MAY RE
__•
Y
2. BOARD OF HEALTH
This individual has be informed of e ermi equirements that pertain to this type of business. MIDST'COMPLY WITH ALL
.HAZARDOUS MATERIALS REGWLATIONS
./Authorized Signatu
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS: -
r
,. Dater/ dam/ -o
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: (-�c '� P� �,C};r (;�fu-P
BUSINESS LOCATION: 460 Fn-,,.e-yS Irx AP 2c INVENTORY
MAILING ADDRESS: 15 t-It� TOTAL AMOUNT-
TELEPHONE NUMBER: 7663
CONTACT PERSON: ItI-qe-lAk-
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: qo�IK-r- ,%
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product- Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery,acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt&roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
yyyy (Including bleach)
Spot removers&cleaning fluids F
(dry cleaners)
Other cleaning solvents
Bug and tar removers
✓Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS plicant's Signature Staff's Initials
'`
-LO AT ON SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME R A0ORESS
1CCO-
0 U I L 0 E R OR OWNER
L12T-L- .SHLtXW _
GATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
Cry A
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