HomeMy WebLinkAbout0452 STRAWBERRY HILL ROAD - Health E= 248
WBERRY HILL RD., HYANNIS
59
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s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name A
information is required for every eille n�I Ma 02632 8/3/2012
" `
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector. �J I
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector.
key.
C y e Enterprises
� Company Name
153 Commercial St.
Company Address
Mashpee Ma 02649
City/Town State Zip Code
508-477-8877 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/3/2012
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DER. The.original should be sent to the-system owner
and copies sent to the buyer, if applicable, and the approving authority.
-****This report only describes conditions-at-the time of inspection'-and uitder'the conditiions of use
� _ .._ e.a.� rr__ ae__
at that time. his inspection does riot a .address o;:t;,.._ 5yv. ..,v..'.
the same or different conditions of use.
61 ,��
l
t5ins•11/10 Title 5"T. m:Subsurface Sewage Disposal System•rage 1-of 17
I
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M ,.•'°� 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 452 Strawberry Hill Rd Centerville is served by 2 seperate Title V septic
systems. This report is for the second system which serves the master bedroom and one bathroom .
This system consits of a 1000 gallon septic tank and a 1000 gallon precast leach pit.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 4_52 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform.bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is
required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. Cityfrown State Zia Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
I
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank (locate on site plan):
Depth below grade: 2
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:
1000 gallons
Sludge depth:
6"
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 101,
How were dimensions determined? opened covers, took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. Water level was ok, tank was not leaking and was structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 �, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1x 1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leach pit showed no signs of pastor present hydraulic overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspection :.Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
452 Strawberry Hill Rd. (Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
a 2
O
O
/7 6"
23,b ,
t3-Z Y/ 6
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State ZPp Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators installers - attach documentation
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 452 Strawberry Hill Rd. ( Secondary System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State . Zlip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
1
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System)
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centervi4e. 0-110K Ma 02632 8/3/2012
page. City/Town State Zip Code Date of inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the:end of the form.
Important:When A. General Information 11
-
filling out forms
on the computer, 4fV (f
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
C y e Enterprises
� Company Name
153 Commercial St.
Company Address
Mashpee Ma 02649
City/Town State Zip Code
508477-8877 SI 4522
Telephone'Number license Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/3/2012
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
• and copies sent to the buyer, if applicable, and the approving authority.
""This:report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�11� u ICJ
SSins•11 M 0 TiNa 5 Official In Forth:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert &Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always comp'dete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 452 Strawberry Hill Rd Centerville is served by 2 seperate Title V septic
systems. This report is for the main system which serves the majority of the house. This system
consits of a 1000 gallon septic tank, and 2 1000 gallon precast leach pits.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 `
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State. Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
• ❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State . Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and ;nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® El information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 . 8/3/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El polyethylene El other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
6"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3'
Scum thickness 3
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. Water level was ok, tank was not leaking and was structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day.
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2 x 1000 gal
leaching
❑ eac g chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
System has 2 leach pits connected in series, the first pit was full to the outlet, the second pit was
found to have approx 4' of standing water with 2' of available leaching and no signs of past hydraulic
overloading.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�M s 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Mt 452 Strawberry Hill Rd. (Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two.permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
a�
r�
d v R
}
o .
Y
A-( 33
5-(
A-Z 3$
B-Z 17
A3 He
z7
t5ins•11/10 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
452 Strawberry Hill Rd. ( Main System }
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
^M 452 Strawberry Hill Rd. ( Main System )
Property Address
Robert&Tracey Mitchell
Owner Owner's Name
information is required for every Centerville Ma 02632 8/3/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
DATE:_7L17f_95 _ . 10
- j
PROPERTY ADDRESS: 452 Strawberry_Hill_RQ.�Ld Cb
--_,Mass 02632ri�
-----------------
On the above date, I inspected the septic system at the above address
This system consists of the following:
1 . 1-1000"ballon septic tank . 1—distribution box . 1-6 ' x7 ' Precast
leacht-rio'pit packed in stone .
Based on m Inspection, I certify the following conditions:
Y p Y 9 i
17:"�T' r;is is a title five septic system. ( 73 Code ) I
2 . The septic system is in proper working order at i
the present time .
I
Recommendations . i
Der-ibution box cover should be raised for servi e ac ess . j
I
SIGNATURE'_ _ f
Name:_j_p_Lac.amhes_jr_-------
i
Company:_J_P _Macomber—& Son Inc .
Address:_ Box 6 6-----------._
("ente. v!1��TMas --112 6 3 2
Phone:_—_ 503_775_3338 -----_
i
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
r
i
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
i
SUBSURFACE SLU AGE DISPOSAL SYSTEM ISSPECTIONFORM
Address of PrOPWO 452 Ornwhorry HiLl Road Centerville &Nss .
Ownwrli Ruth Muldowney
Date of inspacvion 7/ 14 /95
PART A
CHECKLIST
Check if the following have been done :
Yes Pumping information was requested of the owner, occupant, and Board of
Health .
Yos _ None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
Yes - As built plans have been obtained and examined. Note if they are not
available with N/A .
yan The facility or dweilinc,, ,,,as inspected for signs of sewage back—up.
Yes The site was inspected for signs of breakout .
Yes All syste� components , excluding the SAS , have been located on the
site .
Yes The septic tank manholes were uncovered , opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction , dimensions , depth of liquid, depth of
sludge , depth of scum.
Yes - The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
yps The facility owner (anYonrunants , if different from owner) were
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B 1
SYSTEM INFORMATION J
FLOW CONDITIONS
If residential
2 number of bedrooms
[_ number of current residents
0 garbage grinder, yes or no
YES laundry connected to system, yes or no
NO seasonal use , yes or no
If nonresidential , calculated flow:
Water meter readings , if available:
Prr,--e„ tip Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Sg rig ink ��[iLhed n„n� lly for meintenianc_r--_.ji•trr)ose. only .
;la i n tai nr'ci i ] P _ MncQ ^1 ^r c nn TVi Ic- _
r10. System pumped as part of inspection, yes or no
if yes , volume pumped
Reason for pumping :
09
Type of system
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no) ( if yes, attach previous inspection
records, if any)
Other (explain) _
Approximate age of all components. Date installed, if known. S.ource of
information:
l� )R��4 Rnarrl (lf ilr�aI t h T n w n 0f Rarnat,qhI
N0 Sewage odors detected when arriving at the site, yes or no y
1
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: 1-1000 -a7_lon tank
(locate on site plan)
depth below grade : 1 ' _
material of construction : XXXXconcrete metal FRP other(explain)
dimensions : I,=3 ' 6" W=4 ' 10" N=517"
� . sludge depth
distance from top of sludge to bottom of outlet tee or baffle
0 scum thickness
0 distance from top of scum to top of outlet tee or baffle
0 distance from bottom of scum to bottom of outlet tee or baffle
Comments :
(recommendation for pumping , condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs , etc. )
Tank pumped 15 days a!;o . No signs of leakage All tees fine Sch . 41C%
4" PVC pipe . Liguid _Levels inlet 4 ' 6 ' outlet 4 ' 3" No repairs are
necessary . Structurally sound . We Recommend that tank be pumped
once every two to three years .
DISTRIBUTION BOX: Yes
(locate on site plan)
NO depth of liquid level above outlet invert
Comments :
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
D-Rox level distribution equal no carry over of solids . noleaka2e
Recommendat-cn ; Distribution box should be raised .
PUMP CHAMBER: 0
(locate on site plan)
0 pumps in working order, yes or no
Comments :
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs , etc . )
NONE
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : XXX
( locate on site plan , if possible ; excavation not required , but may be
approximated by non-intrusive methods)
If not determined to be present , explain :
Type.
leaching pits and number 1,6 ' x7 ' Precast leach pit .
leaching chambers and number
leaching galleries and number
leaching trenches , number , length _
leaching fields , number , dimensions
overflo4, cesspool , number
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation , recommendations for maintenance or repairs, etc. )
Sand & Gravel ; No signs of hydraulic failure ; No ponding ;
vegetation normal ; No repairs necessary .
CESSPOOLS ( locate on site plan) :
number and configuration NONE
dept.h-top of liquid to inlet invert _
depth of solids layer
depth of scum layer _
dimensions of cesspool
materials of construction
indication of ground,,,,ater
inflow (cesspool must be pumped as
part of inspection)
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
NONE
PRIVY :
( locate on site plan)
materials of construction NONE
dimensions
depth of solids
Comments :
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs , etc. )
NONE
i
draft 1/?3195 1 !
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM IrFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
t
locate all wells within 100' Town 'da t e r
a
1 _ Y9 L
L '
t
1
}
DEPTH TO GROUNDWATER
2[ 1 depth to groundwater
method of determination or approximation:
Test Hole du; on proprty 10/23 94E for the installation of system
13 ' no water .
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not)
NO Backup of sewage into facility?
NO Discharge or ponding of effluent to the surface. of the ground or
surface waters?
-N�J_ Static liquid level in the distribution box above outlet invert?
YES Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
a
NO Required pumping 4 times or more in the last year?
number of times pumped
NO Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS , cesspool or privy:
NO below the high groundwater elevation?
NO within 50 feet of a surface water?
I�� O_ within 100 feet of a surface water supply or tributary to a surface
water supply?
NO within a Zone I of a public well?
NO within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
NO within 50 feet of a private water supply well?
No less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water anal,
for co r lifom bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
TOWN OF Barnstable BOARD OF HEALTH
S(IIIS(IRFACE SEWAGE DISPOSAL SYSTEM INSPFCTION FORM - PART 1) CERTI FT CATION____
—TYPE OR PRINT CT,EARLY—
PROPERTY INSPECTED
STREET ADDRESS 452 Strawberry Hill Road Centerville
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Ruth Muldowney
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P . Macoaber Tr , .
COMPANY NAME J. P .14acomber & Son INC ,
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street--- Town or City State ZIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 503 790 157Y
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
X_XXXX System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED
The inspection which I have conducted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 7/17/95
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doe
C--^,menwear,n cr, masscc:..:secs
Executive Office cr EnvircnmenTC: s
Department of
Environmental Protection
' Water Pollution Ccnrrel Tecnnicel Asswcnce anc Training Secmns
WIWsm F.Weld
Gwwna
Trudy Coil
Soawny,EOEA
Thorns, & Powewe
Ac"corm".-Orw
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Son
PO Box 66
Centerville, MA 02632-
Dear Joseph P. Macomber, Jr. ,
I am pleased to inform you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR 15 . 340 . The passing grade for
the exam was 39/52 or 75% .
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 .
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address :
Kimball Simpson
D.E. P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very much for your time and consideration in this matter.
Sincerely,
Kimball T. Simpson,
DEP Training Center Director
(2 4 0 S) Routs 40 • Millbury, MA 01527 • FAX 508-755-92S3 • Telephone 508-756-7281
Water
Conservation
AVE Tips . . .
CHECK FOR LEAKS
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day Loss Per Month
Size
• 120 3,600
• 300 10,800
• 693 20,790
• 1,200 36,000
• 1,920 57,600
3,096 92,880
® 4,296 .128,980
® 6,640 199,200.
6,9.84 200,520
8,424 252,720
9,888 296,640
® 11,324 339,720
12,720 381,600
14,952 448,560
OLDER A RECENT HOME
FipME
STACK VENT
STACK
A VENT
SEWER PIPE PIPE - SEWER PIPE
r *"}-MANHOLE � --MANHOLE COVERS
A COVER SEPTIC TANK-- ;
CESSPOOL
DISTRIBUTION BOX i
-_..r--i-+TO LEACHING i
FIELD.PIT,
TRENCHES. ,{
Reasonable Steps to take to Prevent System Failures CHAMBERS. 1
OR GALLERIES
DO NOT use garbage disposals, as they are a leading factor of clogged systems.
DO NOT put solids or sanitary napkins, paper towels, grease, hair, oil (including
cooking oil) , colored toilet paper, tissues, or coffee grounds down the drain.
INSPECT on-site systems annually. Do not wait until you have a problem.
PUMP OUT your septic tank or cesspool every two to three years.
CONSERVE WATER: Excess water can create problems. Install water saving
devices wherever possible.
DO NOT put additives into your system. Medicines, paint, paint thinner,
disinfectants, pesticides and acids will only kill the bacteria which are
needed to decompose the organic matter.
DO NOT use enzymes or acid for treating your septic tank or cesspool.
DO NOT plant shrubs or trees with deep roots near your leaching area.
DO NOT allow heavy equipment to drive over the leaching area.
AVOID peak flows by spacing out laundry loads, bathing and dishwashing.
DO NOT put chemicals into the cesspool or leach pit for the purpose of
maintaining or declogging it. Helpful bacteria in the septic tank are upset
by the addition of chemicals.
Maintenance Information
DO NOT USE CESSPOOL CLEANERS. There are no known chemicals, yeasts,
bacteria, enzymes or other substances capable of eliminating or reducing
the sludge and scum so that periodic cleaning is unnecessary. Many of these
cleaners contain highly concentrated organic solvents that are rated toxic
and suspected to be cancer-causing by the EPA and National Cancer Institute.
They are not bio-degradable and pose a serious potential threat to private and
public water supply wells. The use of such products is not necessary for the
proper functioning of a septic system.
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED 7 II J ►�
" DAT E COMPLIANCE ISSUED 1
7- ��� 7x-
r
Ise � yo'
qo
No......3_�21�. F>s. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'_/.. d.....................OF..�.(S.! .,s r 4 .........................................
„����irtt�i�an••'�n� �i��n��1 n�k� C�nn��rn.r�inn rrnti�
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: ��'
---------- ---- ... ....._
Location-Address_ �S or Lot No.
._.. ► ta.1. 1 ----------------------------- ------- �° .............................................................
owner Z ddress
�
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ......................................................
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity,/Q"gallons Length................ Width---------------- Diameter---------------- Depth................
w Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area______-____-_--____sq. ft.
x Seepage Pit No..10 779 i_ __.. Diameter.................... Depth below nlet_.._6........... Total leaching area..................sq. ft.
Z Other Distribution box (A•) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.__-____---____---____.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•----------------------------------•---------------------....--••--•----•--------------------------------------•--•------------•••--•.....
-...
_..............
0 Description of Soil-------------------------------•----...-----------------------------•----------•---------------------------------------------•--------------------------•••••••-••_••...
x
V ....•--••-•••-••••••--....-••••••--••••.....••-•-••••••-•-•----•••-•••--••••-•---••-••.........•-••••••--•---•••••••••-••-•-•••••••-•••-•-••••---••-•----•••--•-••-•••.....-•------•-----•---......••--•-
W ••-•••--------- ------------••-••••-•--••--•--------•-••••••--------•---•-------------•-•-•••-•--•-•---•••......--------••••--------•......•---•=--•••--•-•-
U Na re of Re airs or Alterations—Answer when a plicable/4R4 Y ___60 __ �"*! .......... ....
- -------------
_ . .q.� ?.ail/ • `0`'�"- -=� .�/. 1. _? I. ri �P. T<%!`it:
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI:L,;;:. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h alth.
S. .
Date
Application Approved By.... ,� ........
Date
Application Disapproved for the following reason s..................................................................................................................
......................................................-•--•--•----••--•••••-•-••-•------•..._.
Date
Permit No......................................................... Issued.._. .-. /— �
...................
Date
NC
f THE COMMONWEALTH OF MASSACHUSETTS ;M r
BOARD OF HEALTI-I'
�J`w /----------------OF... aST/ .................................................
AppAiratiou.-Max 3 wpatial Works Touiitr�t�t' r� Pam it
Application is hereby made for a Permit to Construct (;. ) or Repair ( an Individual Sewage Disposal
System at
•• .... ._ s4.?€ J� : .----------•--•------•---••--------- ......
.....---...-- ----
Locatron Address r Al�� or Lot No
O er L +� A,,��� f + ,t Address
�. ------ �--•- --------- ........... ........................... .................................. L.........-..----------
Installer Address
Type Type of Building a Size Lot............................Sq. feet
U Dwelling_'No. of Bedrooms................................. --?_'_Expansion Attic ( )'`` Garbage }Grinder ( )
O.ther—T e of Buildiii No. of persons............................ Showers — Cafeteria
a Other fixtures .-----•--•----------------------•--
W ,Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity/OVVgallons Length................ Width---------------- Diameter----------------- Depth.................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No..1.6_07 _.,.. Diameter.................... Depth below inlet ............. Total leaching area•-•--_•---_.._.._.sq. ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by..................•-•-------.............._---..........---------•--•----- Date........................................
Test Pit`No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water______-___--__,.........
'� ................................................ _..
Descriptionof Soil..............................................................................;........................................................................................
0 ----------------------
-----------------------------
-------------------------------------------•------- --------•---. --- --------------------•••---
W ----•--------- ----------- -------- ----------------•------------- -- --••---•--------- ------------
x i�l, ' e���-•�'
U Nat re of epair or Alterations—Answer when appl>cable ____ __ ____ ___________....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued ly the board of Health.
.: : Application Approved By........................ -----• - ---•--•------�;! ---•---- --••-------------•------- -•------------------Dace__...--•------
Application Disapproved for the following reasons:............................................................-------------------•---_.........................
---•----------•--------------•-•-------------._.....---------.....•-------•------•--. ........................................-.......................................................................
A Date
PermitNo......................................................... Issued-.......................................................
Date
,,THE COMMONWEALTH OF MASSACHUSETTS, ,.3.1
BOARD OF EALTH
......... ......OF....W - .......................................
Trrtiftrati f Tompliana
THIS IS TO CERTIFY, That the Individual Sewage;Disposal_System constructed ( ) or Repaired ( )
9' 4
at............................................... - .•-- .. •------•-•--•--••-•-••-------------------------------•---
has been installed in accordanc with the provisions of TI ° "' tate Sanitary dg s s c�, in the
application,:for Disposal Works Construction Permit No......................................... dated------------------------------------------------
THEEISSUANCE OF THI wCERTIF4CATE.SHALL NOT BE,CONSTR:IIE®�AS:A GUARANTEE T ArT�'THE
�, r{gj y r
-SYSTEM WILL 'FUNCTION SATISFACTORY � �
..eDA N' �.x1�._.a.�i-.L-"->• . . ' Spector
'.....a.• ................._- .....�" """'___•'_•_•__•
r
a: t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® 51 HEALTH
No._._.. FEE...=.....................
Prltitwi:� ;.Awvt_
Permission;is her ra '�? --- .._.. . .y g - ------- Fg;f .
Ito nConstrl i al
It No............................................... --••--•--•-........-- ............................... ------...............
S.
as shown on the application for Disposal Works Construction P No.___.�����%'�� ated--- ---------
" " � .. -- -
�. Boar&of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS