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HomeMy WebLinkAbout0576 STRAWBERRY HILL ROAD - Health 576 Strawberry Mill Road Hyannis A = 249 — 030 i r a Commonwealth of Massachusetts .2y/ -0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' Copy 576 Strawberry Hill Road opert --- — _ — I � Pry Address -- —------------ ela James Ainsworth Owner ------ --------- ---- ----- ---- - —--- Owner's Name --------------- information is / --mT-- ✓ T required for every Hyannis _ MA 02601 _ August 20, 2018 h_--_ 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 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T_S_ullivan use the return ---- key. Name of Inspector ------------ ---- -------------- - --- - Ready Rooter Excavting__ ;b Company Name ----------- 41 PO Box 89 Company Address y — Forestdale MA 02644_ Cityfrown -- -------- -- State Zip Code 508-888-6055 _ -- SI 12843 _ 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 - -August-2- 2, 20-18—n---o— a -- — - Date ---------------- ------- � The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the systenn 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. 51ns.dcc-rev.FIt r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 576 Strawberry Hill Road James Ainsworth information is Name Owner Owner's required for every annis MA 02601 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D AJ System Passes: | have not found any information which indicates that any of the� hai|unechbahadmaohbod in 310CK8R 15.303orin 310CK8R 15.304exiot. Any failure criteria not evaluated are indicated below. — Comments: .Propeqy�as_been vacant for 2+- years. B) System Conditionally Passes: One—_ ormnresyohsmuomponontsasd000rbadinthe ^Conditinna| Pass^ socdonnoedtobe replaced or repaired. The aymbem, 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 thefollowing 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 infiltratiorf/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 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. /»in".*oc-re~e'n Commonwealth of Massachusetts Title 5 Official Su�u�� ��eD�p�| Inspection Not for Voluntary Assessments 576 Strawberry Hill Road Property Address James Ainsworth Owner me information -- required for every Mannis MA 02601 Au nt20 2018 page. City /own S tate B. — Certification `-_-, LJ Pump Chamberpumps/a|annu not operational. System will pass with Board of Health approval if � pumps/alarms are repaired. B) System Conditionally Passes (cnntj: LJ Observation of sewage backup to broken or obstructed pipe(s) �f due to a broken, settled or uneven distribution box. System will pass inspection if(with approv2[l of Board of Health): 0 broken pipe(s) are re�laced D Y n N El ND (Explain below): D distribution b04 leveled or replaced 0 Y El NEI ND (Explain below): The system required pumping more than 4times year due to broken b structed pipe(s). The system will pass inspection if(with approval of th6 Board of Health).- --'-' rr``~/ are replaced , LJ m LJ mu (Explain be|nvv): F] obstruction is removed El Y El N El ND (Explain below): C Further Evaluation is Require'� by the Board of Health: F-1 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 unle(ss Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: El Cesspool or privy is within 5U feet dfa surface water LJ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5i""�oc-rev.m`v Title v Official Inspection Form:Subsurface Sewage Disposal System'Page 3w,, . . . . Commonwealth of Massachusetts ~�~~��N�� 0� Official Q Inspection �� Title � ��� � N�0�� ���������N��� ������- =��°~= mm����~~�� m��wm Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 578Stravvber Hill Road Property Address ---�—�-----------��--------���� James Ain nmmrth Owner m�nnauon� ��— required for every tyan n i MA 02001 Au ot2O 2018 � page. C�w/vwn State Zip`C��--- Date of Inspection � B. Certification (cont.) 2. System will fail unless the Board oJ Health (and Public Water Supplier, if any) � determines that the mystanm is functioning in a manner that protects the public ~health, safety and environment: LJ The system has a septic tank and soil absorption system (SAS) and the SAS is within 1UO feet ofa surface t | ib El The system has a septic tank and SAS a Y� supply. / nd the SAS is within a Zone 1 of a public water 0 The system has a septic tank and SA/S and the SAS is within 50 feet of a private water supply well. I/ 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 wel 1 1**. Method used to determine distance This system passes if the well wa(ter analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent/a/nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided tVat no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable tmAll Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yea No Fl �� Backup ofaevvage into facility or system component due to overloaded nr -� �~ clogged SAS orcesspool Discharge or ponding of effluent to the surface of the ground or surface waters -- �� due to.an overloaded or clogged SAS orcesspool �l �� Static liquid level in the distribution box above outlet inve�due toan overloaded-� �� or clogged SAS orcesspool Liquid depth in cesspool is less than 0^ ba|ovv invert or available volume in less �� ^~ than 1/2 day Movv /o",o""-rev.v,,s Title 5 Official inspection Form:Subsurf lace Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form subsurface Sewage Disposal System Form Not for Voluntary Assessments 576 Strawberry Hill Road Property Address James Ainsworth information is required for every Hyannis MA 02601 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No El M Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. F-1 Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 0 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.] El E The system is a cesspool serving a facility with a design flow of 2000gpd- The system fails. | have determined that one nr more Of the above failure -- -- ohtoha exist aodescribed in 310 CyWR 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: Tmbe considered a large system the system must serve a facility with m � design flow of10'000gpdtoi5.D0Ogpd. � For large syshams, you must indicate either"yes" or"no" to each of the foUovving, in addition to the questions in Section D. / Yes No 11 El the system is within 400 feet of a surface drinking water supply El El the system is Within 200 feet of a tributary to a surface drinking water supply P the syste is located in a nitrogen sensitive area (interim Wellhead Protection Area— PA) or a mapped Zone 11 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 SectKn D above the large system has failed. The owner or operator of any large system considered a sjinificant threat under Section E or failed under Section D shall upgrade the system m accordance/with 310CyWR15.3O4. The system owner should contact the appropriate � regional office of epartment. oin"m���. m,�_ mw5 Official Inspection Form:Subsurface Sewage Disposal System'Page om,r | ' Commonwealth of Massachusetts ^� M Title 5 Official Inspection Form I; i=• Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -3 a 576 Strawberry Hill Road Property Address ----- — --- James Ainsworth Owner ------- —-----—---—------------ --- Owner's Name --- --------------- information is required for every Hyannis _ - — MA—_ 02601 _ August 20, 2018 _ page. CitylTown — _— _ _ 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 ® El information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ 0 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? 0 ❑ 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: M ❑ 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--- l5ins.doc•rev.6/15 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f _ Commonwealth of Massachusetts Title 5 Official Inspection Form (JA _t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address -- ---------- -- James Ainsworth Owner _.--- ----------------------------------------------------------------------------------------------- Owner's Name information is required for every Hyannis __—_ — — _ -MA 02601 August 20, 2018 page. City/Town - Zip Code --.. Date o ------ — State Zip Code Date of Inspection D. System information ------- --- — Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes © No Water meter readings, if available (last 2 years usage (gpd)): Vacant property Detail: Property has been vacant for past several years_ ------------------------------------------------- Sump pump? ❑ Yes ® No Last date of occupancy: 2015+=__-_— Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.20 Gallons per day(gpd) Basis of designf _-.low (seats/persons/sq.ft., etc.): ------- ---___.______--_ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank p- sent? ❑ Yes ❑ No Non-sanitary waste dischar ed to the Title 5 system? ❑ Yes ❑ No Water meter readings, ifAvailable: i t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts -- Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 576 Strawberr Hill R.-� oad --ss ---- ---------- - ----- -- Property Address -------- --- - --___ _ James Ainsworth Owner Owner's Name------- _ —-------------- --- - - -----------------------— - information is ---- -----— required for every Hyannis —_— MA 02601 August 20, 2018 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) _---- Last date of occupancy/use: Date ------ ------- Other(describe below): General Information Pumping Records: Source of information: No records found 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 2 "0 -6-0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 576 Strawberry Hill Road Property Address James Ainsworth Owner Owner's Name information is H annis required for every —Y M A 02601 August 20, 2018 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: System installed 05/01/2000. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? E] Yes Z No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: El cast iron Z 40 PVC El other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.).. ------------ ------------- Septic Tank (locate on site plan): Depth below grade: 1.2 feet Material of construction: Z concrete 0 metal D 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 [:1 No Dimensions: 10.5' x 5.5' x 5' 1500 qallons ------- Sludge depth: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts PIT Title 5 Official Inspection Form m= j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 576 StrawberrY Hill Road -- ----------- ------ --- --------------- Property Address ----- -- ------------- James Ainsworth Owner -- ---------------_---------- -- - - --- Owner's Name information is required for every Hyannis MA 02601 August 20, 2018—_ — - --------- ------- ---- -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) — — - -- Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32-- — -- Scum thickness 01 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 14- ------- --- Dip tube and tape measure. How were dimensions determined? ------ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade. Pumping not needed at time of inspection_ Root intrusion around outlet removed during inspection_ Grease Trap (locate on site plan): Depth below grade: feet Material of construction: �1 ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): - - - - -- - — - - Dimensions: -- ------ ---------- Scum thickness -------- - ------------- Distance from top of sc4m to top of outlet tee or baffle - ---- --- ----------- - Distance from bottom/ of scum to bottom of outlet tee or baffle - --------- Date of last pumping: --- ---- Date 15ins.doc•rev.6/16 Fitle 5 Official Inspection Form:Suhsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments li 576 Strawberry Hill Road — Property Address James Ainsworth ------------------------------------------------- --------- Owner Owner's Name information is required for every Hyannis MA 02601 August 20, 2018 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: /ng: Alarm in working order: ❑ Yes ElNo Date of last pump --- ---------- --- ---- ---- -- Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No i5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 / . . Commonwealth of Massachusetts ��~��0�� �� ��������~��N Inspection ���~���� ����U�0�� Title �� ���� � �����w� N��� ���N��mm ����mmmm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 576 Strawberry Hill Road — Property Address' ��--����--�-----�-- James Ainsworth Owner ��---------------------------�—�— Owner's Name infonnadonio required for�e� H a i MAO28U1 Au t2O 2018 _._ page. City/Town State Zip Code Date of|nupecUon City/Town � D. ~y~'..~... ....~. ....~..~... (^=.`) Distribution Box (if present must be opened) (locate on site p|an): � Depth of liquid |eve| aboveouUetinvert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out ofbox.ietc]� One inlet, one outlet. Light root intrusion removed during inspection. No solids carryover. No high water stainingU invert. Riser � / Pump Chamber(locate on site p|on): Pumps in workingorder: Yes No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Alarms in working order: El Yes El No* | � | ° If pumps or alarms are not in working order, system isa conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): |f SAS not located, explain why: . . . . Commonwealth of Massachusetts Title��~��N�� �� �=����~��~��� N���������*^�~���� ����N°N�� �� ��yNNN��N��� Inspection ����mmmm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property kddress James Ainsworth Own erName � information is � required for every H i s MA O26O1 A :�2O 2018 pogo. Cup/own State Zip Code Date ufInspection D. System Information (cont.) Type: LJ leaching pits number leaching chambers number 4- Infiltrator Hi- leaching gaUahes number leaching trenches number. length: LJ leaching fields number. dimensions: El overflow cesspool number: El innmvabve/a|temativeoystem Type/name oftechnology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Camera used to |onaha and inspect units. Units are top loaded. Dry at time of inspection. No sign of past hydraulic hei| 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 orgnoundwa0arinflow El Yes Fl No ` /5ins.*oc-re~ane Title 5 Official Inspection Form:u"bS"rfa" Sewage Disposal System-Page,2.m`r r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address -- -- -- - JamesAinsworth Owner's-------------- ---------------------------------------------- wner's Name information is required for every Hyannis _ _ _ MA 02601 _ August 20, 2018 page. CitylTown 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 s I, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 15ins.doc•rev,6/16 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 576 Strawberr- Hill Road Property Address ---James Ainsworth Ainsworth Owner Owner's Name -- ------- ---- ----- -------- --- — information is required for every tl�rannis _ — — _ — MA 02601 August 20, 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 I it O I i I 0 I rilli ci) I C) J i l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a=� Title 5 Official Inspection Form 1 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address ---- -------— -- ------"----- -- — -- James Ainsworth Owner - ---------- -—----------- Owner's Name ------- -- -- ------------- information is required for every tennis _ — - — — _ - — MA 02601 Au ust 20, 2018 page. CityrFown -- -- --- — — --- — State Zip Coodede Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '5------------------------------------- feet - Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 04/19/2000 If checked, date of design plan reviewed: -Datteo " --------- ---- ❑ 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: maps.massgis.state.ma.us/oliver_php—- You must describe how you established the high ground water elevation: Ground water Certification form from emergency repair in 2000 shows adj. ground water at elv= 28.6. Base of units at elv= 52 per form. Diff= 24.6. Accessed local ground water contours and topo mapping_No high ground water in area of system Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev 6/1 o Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 _ . , ^ ^ Commonwealth of Massachusetts ��^~����� �� ��u���~�m~��N N���������*^�~���� ����N~N�� ' Title �� n�rmmm��NwwN Inspection Form Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 576 Strawberry Hill Road pmportyauun:os ��------------------------------------ — James Ainsworth Owner --------- ---------- Owner's Name -----------------------'--------'------------------ information is required for every Hyannis MA 02801 August 2U18 u page. t� � Date of Inspection /own State Zip e— ---- E. Report Completeness Checklist 0 Inspection Summary: /\. B. C. D. orEchecked Z Inspection Summary O (System Failure Chhaha Applicable to All Systems) completed Z System |nhonnadon — Esdmated depth tohigh groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file � Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page,rm,r -c 23 2015 2138 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts C" Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 576 Strawberry Hill Road Property Address > Paula Ainsworth - Owner Owner's Name information is e rville MA 02632 12-23-15 required for every C page. C' /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 and of the form. Important:When filling out forms A. General Information on the computer, J �� use only the tab 1. Inspector: " •:� ' key to move your 0 DAMES cursor-do not James D.Sears _ rn use the return =e Name of Inspector V JCr1K.� .G7 key. Capewide Enterprises,LLC Company Name g$ ' ;� 153 Commercial Street IN SP�G�.��`� u1iu,lnn« Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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. 1 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 12-23-15 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. i I I t5ins•Wl3 This 5 Official Inspection Form:6ubsurfeoe Sewage Disposal System•Page 1 of 17 Dec. 23 2015 21:38 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The system is a 1500 Gal. Tank D Box and four chambers. 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): 15ins.3113 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 2 of 17 f Dec 23 2015 21:38 Jim The Inspector Man 5085349919. page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form A s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owners Name information is Centerville MA 02632 12-23-15 required for every State Zip Code Date of Inspection page. Citylrown B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ 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 replaoed ❑ 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 161ns•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Dec 23 2015 21:38 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is MA 02632 12-23-15 required for every Centerville page. Cityr 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 Is less than 6" below invert or available volume is less than '/2 day flow zd 0#1A [Sins-3/73 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Dec 23 2015 21:38 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-1.5 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® 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 Secdon 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. 15ins•3113 This 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Dec 23 2015 21:38 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name Inquired for is Centerville MA 02632 12-23.15 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® 0 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage uisposai System•Page 6 of 17 Dec 23 2015 21:38 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 576 Strawberry.Hill Road Property Address Paula Ainsworth Owner Owners Name information is required for every Centerville MA 02632 12-23-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal Tank D Box and four chambers. 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2014-59,000Gal 2015-46,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: 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/scI t., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑, No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurrace$ewege Dispose System•Page 7 or 17 Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 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: 12-2015 Was system pumped as part cf the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3.113 Title 5 Official Inspeclion Form:Subsurface Sewage Oisposal System•Page 8 of 17 Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: 2000 T Permit#2000 -247. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. Septic Tank (locate on site plan): Depth below grade: 16" 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: 1500 Gal-Precast H -10 Sludge depth: 1.r (Sins•3,113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is Centerville MA 02632 12-23-15 required for every 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 29" Scum thickness 01, Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at 16" below grade. In and outlet tee's. No sign of leakage or over loading. 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-3/13 Title 5 Official Inspect on Form:Subsurface Sewage Disposal System•Page 10 of 17 Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 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 15ins-3113 Title 5 Official InSMCI.on Form:Subsurface Sewage Disposal System•Pape 11 of 17 Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts a Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name Information is required for every Centerville MA 02632 12-23-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan).- Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x21"-21" below grade w/one line out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ' ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located, explain why: i l5ins•3113 Title 50Kcial Inspection Form:Subsurface Sew2ge Disposal Systerr•Page 12 or 17 Dec 23 2015 21:39 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 576 Strawberry Hill Road _ Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. Cilyrrown State Zip Code Date of Inspection D. System Information (cont-) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): Leaching is four infiltrators (10'x30'x2')w/inspection port. Chambers are 25" below grade. 6"water in chambers. No sign of over loading. 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 15ins•3112 Title 5 Official Inspect on Form Subsurface Sewage Disposal System•Page 13 of 17 f Dec 23 2015 21:40 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts � Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. City/Town State Zip Cade 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.): l5inB•3/13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 Dec 23 2015 21:40 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 576 Strawberry awber Hill Ro ad Property Address Paula Ainsworth . Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 f f 0 o I i3y �-3= 12-3 ,' e..� 418 C D f r t5.ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 o117 Dec 23 2015 21:40 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information isequired or every Centerville MA 02632 12-23-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to hFiigh ground water: 28 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: 4-19-00 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: T.H.on Design 4-19-00 no G.W. at 28'. Bottom of leaching at 4'-6"below grade. Bottom of leaching at 24' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3113 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 16 of 17 Dec 23 2015 21:40 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 576 Strawberry Hill Road Property Address Paula Ainsworth Owner Owner's Name information is required for every Centerville MA 02632 12-23-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection.Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins 3113 Tide 5 Off1dal Inspection form:Subsurfsoe Sewage Disposal system Page 17 of 17 Health Master Detail Page 1 of 1 a a,yT p 4� �. Logged In As: TOWN\stantond Health Master Detail Friday, September18 2015 Application Center Parcel Lookup Selection Items Reports Parcel Septic Perc Well Fuel Tank Parcel: 249-030 Location: 576 STRAWBERRY HILL ROAD, HYANNIS Owner: AINSWORTH, PAULA A&JAMES E Business name: Business phone: I Rental property: ❑ Deed restricted: ❑ Number of bedrooms I Contaminant released: ❑ Fuel storage tank permit: ❑ i Save Parcel Changes � Returri to Lookup Parcel Info Parcel ID: 249-030 Developer lot: Location:576 STRAWBERRY HILL ROAD Primary frontage:240 Secondary road: Secondary frontage: village:HYANNIS Fire district:HYANNIS Town sewer exists at this address:No Road index: 1546 Asbuilt Septic Scan: 249030_1 Interactive map r WP (Wellhead Protection Overlay Town zone of contribution:District) State zone of contribution:IN Owner Info Owner: AINSWORTH, PAULA A &JAMES E Co-Owner: Streetl:576 STRAWBERRY HILL RD Street2: City:CENTERVILLE State:MA Zip: 02632 Country: Deed date: 10/29/2003 Deed reference: 17857/4 Land Info Acres: 0.30 Use: Single Fam MDL-01 Zoning;SPLIT RD-1;RB Neighborhood: 0104 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1925 1742 896 12 Bedroomsl Full-0 Half Buildings value:$59,700.00 Extra features: $17,100.00 Land value: $67,400.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=249030 9/18/2015 TOWN OF B` RVSTABLE 1 LOCATION 7 y��ie-rl A�"ll e LE" SEWAGE # VILLAGE _'!ASSESSOR'S MAP & LOT INSTALLER' AME&PHONE NO. 7-1--4:! SEPTIC TANK�CAPAC= P4140IS�dD L LEACHING FACILITY: (type) 4 (size) Safi vk , �Q'�c 3a'xo2 NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: i- Sepaiition Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ` Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Ilih, - Feet Furnished by 13 C-1c rDd �ay�sor , o. •;r� ASS 1A f OA'0w� P � qse �► f h+ O j� M6 No. 77 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for ]Di9;poga1 *pgtem (Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) EA Complete System ❑Individual Components Location Address or Lot No. 76 � ���//;y�f �� Owner's Name,Address and Tel.No. Assessor'sMap/Parcel All��A i0k / �-Yxi-41 n, Installer's Name,Address, Tel.No. Designer's Name,Address and Tel.No. 7;7i-9�� Type of Building: Dwelling No.of Bedrooms i"? Lot Size sq. ft. Garbage Grinder( /40 Other Type of Building<7G No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /f p- gallons per day. Calculated daily flow � ga llons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1` ®D Type of S.A.S. — r' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued Wth*so of Health. Signed Date /�/ Application Approved by Date Application Disapproved fotVe following reasons Permit No. Date Issued y i 7 l \ ems" ^s:y .•i �k '� 't _'sr '} ,ram i� (/ � t� ��f/+j��J/� � ✓.- A q 1! " No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Y ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Migooar *p!5tem (Cone;truction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) E omplete System ❑Individual Components Location Address or Lot No. C`76 Jt.1W A4e 1/y` 1111, Owner's Name,Address and Tel.No. Assessor's Map/Parcel / (// v ' r�6(� yW51i n� Installer's Name,Address, Tel.No. Designer's Name,Address and Tel.No. 771 Type of Building: Dwelling No.of Bedrooms I.? Lot Size sq. ft. Garbage Grinder( Other Type of Building'QP_5i�!'G No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow//4�9 gallons per day. Calculated daily flow .33el) gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank DO Type of S.A.S. — `t %`/a loss Description of Soil DX� - Nature of Repairs or Alterations(Answer when applicable) .Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oar 4 of Health. / Signed A / Date y Application Approved by Date Application Disapproved foAfhe following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, th t the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by D 6l at D e has bean constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this vermit shall not be construed as a guarantee that the sy�,*1111n as designedDate . �2' ""' s Inspectorf v V�V — ---------------- -- 4 � ! � Fee ''- No. T & - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mi!6po5ar *pgtem Cottgtruction Permit Permission is hereby granted to Construct( )/Repair U grade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided:Construction must a com leled within three years of the date of -s per-snit. Date: "f Uo Approved by t IN" NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CER TIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) h hereby certify that the application for disposal works construction permit signed by me dated 41/WA , concerning the property located at �� j`!"�IG��f'P!'` /�l >GY� meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business es associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed 2There are no variances requested or needed. i✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor ethod when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 2 +the MAX High G.W. Adjustment. DIFFERENCE BETWEEN A and B 475 , SIGNED :—AL2 DATE: I [Sketch proposed plan of system on back]. q:health folder pert 1y�4 �'.7`ki'sY'x��. a •'3`,sox La ` €�,.kr -i ;v`a r.8 - f%.A tts $yii�vr '�' 5�:;.; rk 3"-t"-,, > ;�...tR-..(tea x Ck.'�' �'+�.�^ v'7`3 g ':}''�', ° 3-� �p.•i;a,`x,.. sy.' .,. Fb ® 65'i,� 1 t i I TOWN OF BA STABLE LOCATION SEWAGE # � VILLAGE C /e-VZ! �`/e ASSESSOR'S MAP & LOT INSTALLER'S NAME&'PHONE NO. 'o1' ���` -f✓ '✓�T 7/— � ll SEPTIC TANK CAPACITY %.SdO L LEACHING FACILITY: (type) ry a (size) '/o,<3a 'X a :-.. .. NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE; Separation Distance Between the Maximum-Adjusted Groundwater Table o the Bottotn of:Leaching Facility, S f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) X1 Feet Furnished by CZ .of Dd ro'f'a�sAj- S� O qs� A f"< h� O/�