HomeMy WebLinkAbout0818 SOUTH MAIN STREET - Health 818 South Main Street, Centerville
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SI-24-301
Title V State of MA Inspection Report – Filed with Health Division · Add to a project
Active Request Changes
(/#/explore/request-changes/412658)
Expiration Date
Details
Submitted on Jul 19, 2024 at 8:00 am
Attachments
1 file
Activity Feed
Latest activity on Aug 22, 2024
Applicant
Taylor Court 0
Location
818 SOUTH MAIN STREET, Centerville, MA 02632
Septic Inspection Report Filing Fee
Paid Aug 09, 2024 at 9:11 am
Administrative Review
Completed Aug 09, 2024 at 9:53 am
Health Inspector Review
In Progress
View Edit Workflow
Health Inspector Review
Became active 13 days ago
Active
Assignee
David Stanton
Due date
None
Remove Note • Aug 13, 2024 at 11:25 amDavid Stanton
@Thomas McKean this came in as NFE. I also received an e-mail
about this property as well ( I will forward it to you as well.) NFE is
because owner is looking to determine the number of bedrooms
allowed/designed for. Our records are pretty scarce with several
title V inspections saying it had capacity for 440 GPD down to 220
GPD. Not sure if they should hire a designer to determine the
capacity? You signed off on a septic permit 86-771 for 2 bedrooms
for them to restone the SAS. It appears to be 4 flow diffusors from
the early 1970's with a tank and pump chamber. 1974 a building
permit was approved for 1 bedroom only, but was pending a septic
location, and in 1978 Ed Kelly submitted a septic location. Outside
zone II, WP/AP, however they are in the Estuary protection and the
house is right on the river, the tank appears to be about 50' from the
river (note: Ed Kellys plans showing the septic location are in the
building div files, not Health.)
Remove Note • Aug 21, 2024 at 12:54 pmGandolfi
@David Stanton @Thomas McKean @Kathryn Soto Property owners
stopped by looking for an answer on this property.
Remove Note • Aug 21, 2024 at 1:29 pmThomas McKean
Two bedrooms are listed on the DSCP record- plus one bedroom
approved in 1974. . [Note: Bedrooms counts are not used for NFE
and Failure criteria according to Title 5].
Remove Note • Aug 22, 2024 at 8:30 amDavid Stanton
Thanks @Thomas McKean so do you want me to have him update
his report to a pass, keep it as 2 bedrooms actual and 3 bedroom
design?
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton I have no objections tot wo bedrooms based on the
official records. I also have no objections to three bedrooms
maximum if the SAS has sufficient capacity.
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton Also, yes it is a "pass,"
Remove Comment • Aug 22, 2024 at 12:00 pmDavid Stanton
Hi Taylor/Michael, the report has been reviewed as well as the old
Building and Health files. The report can be updated and re-
attached in this same inspection number SI 24-301 as a pass. The
design can be changed to 3 bedrooms as they have four flow
diffusors with stone and the property is only in the Estuary
protection which limits it to 3 bedrooms maximum based on the lot
size.
r
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
V�
Property Address
r
Todd Kittredge
Owner Owner's Name /
information is required for every Centerville ✓ Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms i�A. Inspector Information l#- ( (o94
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites path
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal.systems. After conducting this inspection I have determined
that the system:
1. ® Passes
� �-�Nk OF S���'�
2. El Conditionally Passes .�`��� '' 's9''�.
MICHAEL
3. ❑ Needs Further Evaluation by the Local Approving Authority =o; SEARS
No.SI14430 y
4. ❑ Fails Ao o
S I N SP .
nnnnuW
7-20-20
Inspector's 5 ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c � Commonwealth of Massachusetts
,1P Title 5 Official Inspection Form
.IIn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in 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):
Further r f 3) urt er Evaluation is Required by the Board Health:o
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
k tiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
To be considered a large system the system must serve a facility with a
5) Large Systems: g y y y �
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
2018- 53000 gal
Water meter readings, if available (last 2 years usage(gpd)): 2019- 53000 gal
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... 818 South Main st
V�
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 60"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
u—
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 50"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
24"
2"
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle wall with cover at 8" under bricks, outlet cover 50" under bricks
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<`I; Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No"
Alarms in working order: ® Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
1000 gal pump chamber at 4' below grade with cover at 1'below grade
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
k_ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 4 flow diffusers no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ti, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15'
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:
Gaheerty & Miller Model 12-16-94
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is Centerville Ma. 02632 7-20-20
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Gr4dC
y�
PWam of SAS _ t5•
ll�
6r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r4 � Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: /
When filling out A. General Information ��--
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key: Capewide Enterprises,LLC
Company Name
rL P.O.Box 763
Company Address
Centerville Ma 02632
City/Town. State Zip Code
(505)428-4028
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the;4
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 t6-Section915.340,of
Title 5 (310 CMR 15.000). The system: _ '
® Passes c 7:`Z
❑ Conditionally Passes ❑ Fails
�i
❑ Needs Further Evaluation by the Local Approving AuthorityCD r
20/02/07
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
:pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection,
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further.Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,'safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
` D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 1-5.303, 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.
818 s.main•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
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 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 maintenance f proper a ce o 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)]
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is Centerville. Ma 02632 02/02/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
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
000
,:22
Water meter readings, if available (last 2 years usage (gpd)): 2002005: 2, 0
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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:
Last date of occupancy/use: Date
Other(describe):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
6"
Depth below grade: 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.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
4'
Depth below grade: 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: 8'6"X4'10"X57"
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 0
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Measured
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
onw ea
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2-3 years.lnlet and outlet tees are in place.Tank is structurally sound.No
evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address .
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑.No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
L_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is structurally sound.Pump and alarm are working properly.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 Flowdiffusers
❑ 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.):
Sandy soil.Flowdiffusers were dry at time of inspection.No signs of hydraulic failure.Vegetation
appears normal.
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow , ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
c
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
t9'
�6' I o t
CG
818 s.main•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 15'
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:
As-Built Card.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 Ground Water Elevations Above Sea Level.Used:Observation
Well Data June 1992 Used:Technical Bullettin 92-000-1 Plate#2 Annual ranges of ground water
elevations January 1992.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
l
0 fs
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL, �f<PAk 121
DEPARTMENT OF ENVIRONMENTAL ,(�r �TECT ON V*
ONE WINTER STREET. BOSTON. MA 02108 617-2 15'50000
CT F®
WILLIAM F.WELDTy�oTeg9iy� 1�'q UDY CORE
Governor /" 1 494t 4% Secretary
ARGEO PAUL CELLUCCI ID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO 5 Commissioner
PART A g
CERTIFICATION
Property Address: 81 8 S Main St, Centerville Address of Owner: Robert Baker
Date of Inspection: 16^C 9 17 (If different)
Name of Inspector: Wm E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Cent-Prvi 1 1 P, MA 02632
Telephone Numbers 50, ^ 7 7 5_R 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
71 Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: : Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The System will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wde Web: http:/twww.magnet.state.ma.us/dep
a�j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: `�y� G 17
B) STEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
" Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
0 broken pipe(s) are replaced
obstruction is removed
C) FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic health, safety and the environment.
1), SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
SYSTEM WILL FAIL UNLESS THE BOARD Of HEALTH (AND PUBLIC WATER SUPPLIER, If APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3 OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Dl STEM FAILS:
You m t indicate ei;,,er "Yes" or "No" as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
t failure.
Yes N
Backup of sewage into facility or system component due to an 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 1/2 day flow.
4;
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LAR E SYSTEM FAILS:
You m st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No v
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Id -7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye No
1_/ _ Pumping information was provided by the owner, occupant, or Board of Health.
t✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal
Y P
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ 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.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
_2
(ravimad 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:� <� lO g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):_A,_p
Laundry connected to system (yes or no): L-5
Seasonal use (yes or no): /�
Water meter readings, if available (last two (2) year usage (gpd): 1995 — 89,000 gals
Sump Pump (yes or no): d-0 1 9 9 6 - 66 , 000 gals
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design low: gallons/day
Grease rap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available.
Last lof
of occupancy:
OTHDescribe)
Last occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source f information:
System pumped as part of inspection: (yes or no)_A-
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
1-1 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)
1/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: j';'64
b
Sewage odors detected when arriving at the site: (yes or no)Ard
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: ��r��� 7
BU ING SEWER: /
(local on site plan)
Depth low grade:
Materia of construction: _cast iron _40 PVC _other (explain)
Dista a from private water supply well or suction line
Diamet r
Comm ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: / -I-- Ae
L
Sludge depth: 5'—S
Distance from top of sludge to bottom of outlet tee or baffle:3rt
Scum thickness:/— 3 , r i
Distance from top of scum to top of outlet tee or baffle: t
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: tj gf
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level-inn relation to outlet invert, structural
integrity, evidence of leakage, etc.) j-�+— �.� ��1 a� 7 4
GRE SE TRAP:
(locate on site plan)
Depth b low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ons:
Scum ickness:
Dista ce from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Commen s:
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: %8^�
T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(lo eon site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dim sions:
Capad gallons
Design low: gallons/day
Alarm I vel: Alarm in working order_Yes; _ No
Date of previous pumping:
Comm nts:
(cond' ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: (/
(locate on site plan)
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, etc.)_=j
PUMP CHAMBER:`^
(locate on site plan)
Pumps in working order: (Yes or No) fZ-s
Alarms in working order (Yes or No)
Comments: T— l �� / O
(note condition of pump chamber, condition of pumps and appurtenances, etc.). /G>4-� L.,',�/ + 67 6 csc�J
A.
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(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, number:_
leaching chambers, number.
leaching galleries, number:
leaching trenches, number,Iength:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition oil, signs of hydraulic failure, level of p ndin , condition of vegetation, etc.) s
a C ,-
� a
CE POOLS: _
(loca on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimens ns of cesspool:
Materia s of construction:
Indicat' n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Com ents:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI
(loca on site plan)
erials of construction: Dimensions:
De p h of solids-
Com ents:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Je �G�q�
1 ✓
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks 1L
locate all wells within 100' (Locate where public water supply comes into house)
u/
0
1 Q
1
(revised 04/25/97) Page 9 of 10
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Depth to Groundwater/A Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V/Observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
(/ Use USGS Data
Describe in
our own words how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
SSOR'S MAP NO. / 93' PARCEL S�
LUO;�:�► TION SEWAGE PERMIT NO.
M? SO m,4;,-
L
VI �, AGE
I N S T A LLER'S NAME A ADDRESS
g-,5510.�
71 ,0 c olfe If
S UI�` DE R OR OWNER
�1
�T 9.4 kEA
DATE PER_ IT ISSUED
DATE COMPLIANCE ISSUED
fn
••n' � 1 I
a •
A
II
E`er
LOC-ATION $ E AGE PE RTIJ NO.
e:�o7— -3 rl ..
VILE AGE
INST LLER'S NAME i ADDRESS
41
s ul E oR o` aE
DATE PERMIT ISSUED �y7�
DATE COMPLIANCE ISSUED &�,
i �c
r
a
s
73.
b
oa o � I
y
to
,v
t- ASSESSORS MAP NO: I Or
,7 PARCEL NO.: f�
No. ..:" .... Fims............................. `
THE COMMONWEALTH OF MASSACHUSETTS _._
BOARD OF HEALTH
..........................................OF..........................................-----................----...---.................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...........,?/Ja
..................r.�f �9 ....�?_.. .......................•............--.......--.-----.---.--...............•.......-•.............
/ �1 ocatio d,{iress or Lot No.
Ow�er Address
a �f.!e�e!1_...._.1l:._L✓f/!_!z- ...................................
Installer Address
d Type of Building Size Lot..._ ____________________Sq. feet
U Dwelling—No. of Bedrooms.................... . Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity_ ...gallons Length................ Width................ Diameter................ Depth__..-_____---_-.
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___-___-----------sq. ft.
Seepage Pit No..................... Diameter..............._.--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
f
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
a -•••-----••---------------------•-------------•-•---------------------•-------• -------------
--------------------------------
0 Description of Soil............................................
x
U •-------------------------------------------------------------------------------------------------------------------------------------...........................................................
W ---------•----- ---------------••---------------•••-----•--•---------•-----••--•-••...--•------•---- ------------ --------------•-•,
........................ ....................
of Repairs or Alterations—Answer when a lic ble............ A.1 .F!�f't_........ lT. ..___�.G..._./:_
U P c� PP -• - f {-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TILTH.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Cert sate of Compliance has been ' by the boar f health.
Si Signed
- - -- . -- �----- ................
g �y
Application Approved BY --..._....._ ..a.. /�'.. ��.... ...._..
....................................... .........._.
Date
Application Disapproved for the following reasons-------------------------------------------------- ..............................................................
...................................................................................................................................--------------------------•--•--•-----------...-••-•---•....._------
"rl 1 Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTSQ
BOARD OF HEALTH .
................. ................OF................................-......
Appliration for Bigpas al Warkii Tumtrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: (�
Ali J t U�lf��n Jr
f/�
..............................................•---------------•-•-......-•------"-"------....... '....--"•-•-----......._..............._....._......,------'•"----'-...........................
1,4
1 �Locatio A;,dress or Lot No....... .....!/){r ................. !L 11 4LK.---•--............................ ..........--............................. ................---
/�A O/Wner Address
a -•••--.lam--..-.-#.n......-. /. �/_f r1 l--------------------------------------
Installer _Address
of Building
a TypeDwelling—No. of Bedrooms...................--__--.----_-----------Expansion Attic ( ) Size Lot-Garbag Grinderq feet
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4 Other fixtures ..--...
W Design Flow............................................gallons per person per day. Total daily flow--...........-_............................--gallons.
WSeptic Tank—Liquid capacityJ.'Y ...gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—.\Io..................... Width.................... Total Length.................... Total leaching area----_._--._---._.-__sq. ft.
Seepage Pit Nb-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................--.. Depth to ground water....----...........----.
P�4 Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water..--....................
....................................................................................................................•------------------•----•-----....•..--•--
04•
Descriptionof Soil.......................................................................................................................................................................
W
U --------------------•----•------••••....----•------••--••--•--------------•--------•--------...----........_..------••'-'--------•-------•--•-•-------•---••-•---•-•-•-•--------------'---•---------•---
W
..........................................................--------------------------------------------•---•------- y
x ------------------------ ,
V N�artyre of Repairs or Alterations—Answer when appli ble.--.....--- . _.e. �1�/C _____-_ �, ____•E.c,�?_ _r X.-----,t�
G._..._..-_.!�_l f�!t_r7N. �°f E?. l�P?......r/fo rr �r l % ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i?_LEI, j of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Cer iiicate of Compliance has been ' s byf the boar -of health.
*� Signed. C ..................................................
--- =�� ..01-
C.
Apphcat>on Approved By ..... �'`.... ... ............... =---------- ---- -------- --------.----------
Date
Application Disapproved for the following reasons:-------•-----------------------------------------------------------------------•------------•-••---•-......_.._
...............•.....------------------. --•----•-•-----...-------•-•--------•-••---------•----....----•••---•'------------•---•--•---------....----------------•----•-•••--•--•----------••...------
Date
PermitNo.. ........................................��� Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEALTH
.....!.....PW. .........OF........ �NSZ A-'( 1 C
...............................................•------
Trrtifiratr of ToutpliFanrr
THIS IS._ O._-CER,TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by--------------- 'r '�")....-•--. - u --------•--•.
C" ':::�--Knstaller
T
at............. ............. ------ =^-------•----------- --- ......--
has been installed in accordance with the provisions of i i ii,L j of The State Sanitary e s described in the
�o
application for Disposal Works Construction Permit No.�._.�.y_._."T._' 1__I._._._._ dated........... ......... ._--..-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM W L N SATISFACTORY. t----
DATE.. ' ......................................... Inspector....L --------•-.....------------•---•--•-•---••-----...........-'---.......
THE COMMONWEALTH OF MASSACHUSETTS
t' BOARD OF HEALTH ®
VJ fV
............................. .. ........�............_.�.....`...�"...'...............................................
l�rv' .................. t'EE. ...
'/��ailan rrmi�
Permission is hereby granted................. .!. ....tom,._ .N �--------------•---.
to ConstW,, or Rkpmr ) an Ind' ' -ual Sewa a Disposal System
r . ¢ L-
Street
as shown on the application for Disposal Works Construction Permit i� `7�_. Dated...........�-'6 X15--_---.....
' r / 4
y\ oard'of Health „1
DATE- >- � ...................... �-
FORM 1255 HOBBS & wARREN�NC, PUBLISHERS �}
SI-24-301
Title V State of MA Inspection Report – Filed with Health Division · Add to a project
Active Request Changes
(/#/explore/request-changes/412658)
Expiration Date
Details
Submitted on Jul 19, 2024 at 8:00 am
Attachments
1 file
Activity Feed
Latest activity on Aug 22, 2024
Applicant
Taylor Court 0
Location
818 SOUTH MAIN STREET, Centerville, MA 02632
Septic Inspection Report Filing Fee
Paid Aug 09, 2024 at 9:11 am
Administrative Review
Completed Aug 09, 2024 at 9:53 am
Health Inspector Review
In Progress
View Edit Workflow
Health Inspector Review
Became active 13 days ago
Active
Assignee
David Stanton
Due date
None
Remove Note • Aug 13, 2024 at 11:25 amDavid Stanton
@Thomas McKean this came in as NFE. I also received an e-mail
about this property as well ( I will forward it to you as well.) NFE is
because owner is looking to determine the number of bedrooms
allowed/designed for. Our records are pretty scarce with several
title V inspections saying it had capacity for 440 GPD down to 220
GPD. Not sure if they should hire a designer to determine the
capacity? You signed off on a septic permit 86-771 for 2 bedrooms
for them to restone the SAS. It appears to be 4 flow diffusors from
the early 1970's with a tank and pump chamber. 1974 a building
permit was approved for 1 bedroom only, but was pending a septic
location, and in 1978 Ed Kelly submitted a septic location. Outside
zone II, WP/AP, however they are in the Estuary protection and the
house is right on the river, the tank appears to be about 50' from the
river (note: Ed Kellys plans showing the septic location are in the
building div files, not Health.)
Remove Note • Aug 21, 2024 at 12:54 pmGandolfi
@David Stanton @Thomas McKean @Kathryn Soto Property owners
stopped by looking for an answer on this property.
Remove Note • Aug 21, 2024 at 1:29 pmThomas McKean
Two bedrooms are listed on the DSCP record- plus one bedroom
approved in 1974. . [Note: Bedrooms counts are not used for NFE
and Failure criteria according to Title 5].
Remove Note • Aug 22, 2024 at 8:30 amDavid Stanton
Thanks @Thomas McKean so do you want me to have him update
his report to a pass, keep it as 2 bedrooms actual and 3 bedroom
design?
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton I have no objections tot wo bedrooms based on the
official records. I also have no objections to three bedrooms
maximum if the SAS has sufficient capacity.
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton Also, yes it is a "pass,"
Remove Comment • Aug 22, 2024 at 12:00 pmDavid Stanton
Hi Taylor/Michael, the report has been reviewed as well as the old
Building and Health files. The report can be updated and re-
attached in this same inspection number SI 24-301 as a pass. The
design can be changed to 3 bedrooms as they have four flow
diffusors with stone and the property is only in the Estuary
protection which limits it to 3 bedrooms maximum based on the lot
size.
r
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
V�
Property Address
r
Todd Kittredge
Owner Owner's Name /
information is required for every Centerville ✓ Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms i�A. Inspector Information l#- ( (o94
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites path
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal.systems. After conducting this inspection I have determined
that the system:
1. ® Passes
� �-�Nk OF S���'�
2. El Conditionally Passes .�`��� '' 's9''�.
MICHAEL
3. ❑ Needs Further Evaluation by the Local Approving Authority =o; SEARS
No.SI14430 y
4. ❑ Fails Ao o
S I N SP .
nnnnuW
7-20-20
Inspector's 5 ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c � Commonwealth of Massachusetts
,1P Title 5 Official Inspection Form
.IIn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in 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):
Further r f 3) urt er Evaluation is Required by the Board Health:o
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
k tiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
To be considered a large system the system must serve a facility with a
5) Large Systems: g y y y �
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
2018- 53000 gal
Water meter readings, if available (last 2 years usage(gpd)): 2019- 53000 gal
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... 818 South Main st
V�
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 60"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
u—
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 50"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
24"
2"
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle wall with cover at 8" under bricks, outlet cover 50" under bricks
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<`I; Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No"
Alarms in working order: ® Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
1000 gal pump chamber at 4' below grade with cover at 1'below grade
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
k_ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 4 flow diffusers no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ti, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t
0 �
F�oh� A 1
10
a0
a�
C
0
0
y
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15'
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:
Gaheerty & Miller Model 12-16-94
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is Centerville Ma. 02632 7-20-20
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Gr4dC
y�
PWam of SAS _ t5•
ll�
6r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r4 � Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: /
When filling out A. General Information ��--
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key: Capewide Enterprises,LLC
Company Name
rL P.O.Box 763
Company Address
Centerville Ma 02632
City/Town. State Zip Code
(505)428-4028
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the;4
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 t6-Section915.340,of
Title 5 (310 CMR 15.000). The system: _ '
® Passes c 7:`Z
❑ Conditionally Passes ❑ Fails
�i
❑ Needs Further Evaluation by the Local Approving AuthorityCD r
20/02/07
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
:pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection,
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further.Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,'safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
` D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 1-5.303, 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.
818 s.main•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
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 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 maintenance f proper a ce o 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)]
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is Centerville. Ma 02632 02/02/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
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
000
,:22
Water meter readings, if available (last 2 years usage (gpd)): 2002005: 2, 0
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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:
Last date of occupancy/use: Date
Other(describe):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
6"
Depth below grade: 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.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
4'
Depth below grade: 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: 8'6"X4'10"X57"
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 0
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Measured
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
onw ea
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2-3 years.lnlet and outlet tees are in place.Tank is structurally sound.No
evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address .
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑.No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
L_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is structurally sound.Pump and alarm are working properly.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 Flowdiffusers
❑ 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.):
Sandy soil.Flowdiffusers were dry at time of inspection.No signs of hydraulic failure.Vegetation
appears normal.
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow , ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
c
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
t9'
�6' I o t
CG
818 s.main•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 15'
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:
As-Built Card.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 Ground Water Elevations Above Sea Level.Used:Observation
Well Data June 1992 Used:Technical Bullettin 92-000-1 Plate#2 Annual ranges of ground water
elevations January 1992.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
l
0 fs
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL, �f<PAk 121
DEPARTMENT OF ENVIRONMENTAL ,(�r �TECT ON V*
ONE WINTER STREET. BOSTON. MA 02108 617-2 15'50000
CT F®
WILLIAM F.WELDTy�oTeg9iy� 1�'q UDY CORE
Governor /" 1 494t 4% Secretary
ARGEO PAUL CELLUCCI ID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO 5 Commissioner
PART A g
CERTIFICATION
Property Address: 81 8 S Main St, Centerville Address of Owner: Robert Baker
Date of Inspection: 16^C 9 17 (If different)
Name of Inspector: Wm E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Cent-Prvi 1 1 P, MA 02632
Telephone Numbers 50, ^ 7 7 5_R 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
71 Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: : Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The System will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wde Web: http:/twww.magnet.state.ma.us/dep
a�j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: `�y� G 17
B) STEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
" Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
0 broken pipe(s) are replaced
obstruction is removed
C) FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic health, safety and the environment.
1), SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
SYSTEM WILL FAIL UNLESS THE BOARD Of HEALTH (AND PUBLIC WATER SUPPLIER, If APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3 OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Dl STEM FAILS:
You m t indicate ei;,,er "Yes" or "No" as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
t failure.
Yes N
Backup of sewage into facility or system component due to an 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 1/2 day flow.
4;
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LAR E SYSTEM FAILS:
You m st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No v
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Id -7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye No
1_/ _ Pumping information was provided by the owner, occupant, or Board of Health.
t✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal
Y P
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ 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.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
_2
(ravimad 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:� <� lO g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):_A,_p
Laundry connected to system (yes or no): L-5
Seasonal use (yes or no): /�
Water meter readings, if available (last two (2) year usage (gpd): 1995 — 89,000 gals
Sump Pump (yes or no): d-0 1 9 9 6 - 66 , 000 gals
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design low: gallons/day
Grease rap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available.
Last lof
of occupancy:
OTHDescribe)
Last occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source f information:
System pumped as part of inspection: (yes or no)_A-
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
1-1 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)
1/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: j';'64
b
Sewage odors detected when arriving at the site: (yes or no)Ard
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: ��r��� 7
BU ING SEWER: /
(local on site plan)
Depth low grade:
Materia of construction: _cast iron _40 PVC _other (explain)
Dista a from private water supply well or suction line
Diamet r
Comm ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: / -I-- Ae
L
Sludge depth: 5'—S
Distance from top of sludge to bottom of outlet tee or baffle:3rt
Scum thickness:/— 3 , r i
Distance from top of scum to top of outlet tee or baffle: t
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: tj gf
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level-inn relation to outlet invert, structural
integrity, evidence of leakage, etc.) j-�+— �.� ��1 a� 7 4
GRE SE TRAP:
(locate on site plan)
Depth b low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ons:
Scum ickness:
Dista ce from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Commen s:
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: %8^�
T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(lo eon site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dim sions:
Capad gallons
Design low: gallons/day
Alarm I vel: Alarm in working order_Yes; _ No
Date of previous pumping:
Comm nts:
(cond' ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: (/
(locate on site plan)
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, etc.)_=j
PUMP CHAMBER:`^
(locate on site plan)
Pumps in working order: (Yes or No) fZ-s
Alarms in working order (Yes or No)
Comments: T— l �� / O
(note condition of pump chamber, condition of pumps and appurtenances, etc.). /G>4-� L.,',�/ + 67 6 csc�J
A.
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(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, number:_
leaching chambers, number.
leaching galleries, number:
leaching trenches, number,Iength:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition oil, signs of hydraulic failure, level of p ndin , condition of vegetation, etc.) s
a C ,-
� a
CE POOLS: _
(loca on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimens ns of cesspool:
Materia s of construction:
Indicat' n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Com ents:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI
(loca on site plan)
erials of construction: Dimensions:
De p h of solids-
Com ents:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Je �G�q�
1 ✓
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks 1L
locate all wells within 100' (Locate where public water supply comes into house)
u/
0
1 Q
1
(revised 04/25/97) Page 9 of 10
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Depth to Groundwater/A Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V/Observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
(/ Use USGS Data
Describe in
our own words how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
SSOR'S MAP NO. / 93' PARCEL S�
LUO;�:�► TION SEWAGE PERMIT NO.
M? SO m,4;,-
L
VI �, AGE
I N S T A LLER'S NAME A ADDRESS
g-,5510.�
71 ,0 c olfe If
S UI�` DE R OR OWNER
�1
�T 9.4 kEA
DATE PER_ IT ISSUED
DATE COMPLIANCE ISSUED
fn
••n' � 1 I
a •
A
II
E`er
LOC-ATION $ E AGE PE RTIJ NO.
e:�o7— -3 rl ..
VILE AGE
INST LLER'S NAME i ADDRESS
41
s ul E oR o` aE
DATE PERMIT ISSUED �y7�
DATE COMPLIANCE ISSUED &�,
i �c
r
a
s
73.
b
oa o � I
y
to
,v
t- ASSESSORS MAP NO: I Or
,7 PARCEL NO.: f�
No. ..:" .... Fims............................. `
THE COMMONWEALTH OF MASSACHUSETTS _._
BOARD OF HEALTH
..........................................OF..........................................-----................----...---.................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...........,?/Ja
..................r.�f �9 ....�?_.. .......................•............--.......--.-----.---.--...............•.......-•.............
/ �1 ocatio d,{iress or Lot No.
Ow�er Address
a �f.!e�e!1_...._.1l:._L✓f/!_!z- ...................................
Installer Address
d Type of Building Size Lot..._ ____________________Sq. feet
U Dwelling—No. of Bedrooms.................... . Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity_ ...gallons Length................ Width................ Diameter................ Depth__..-_____---_-.
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___-___-----------sq. ft.
Seepage Pit No..................... Diameter..............._.--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
f
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
a -•••-----••---------------------•-------------•-•---------------------•-------• -------------
--------------------------------
0 Description of Soil............................................
x
U •-------------------------------------------------------------------------------------------------------------------------------------...........................................................
W ---------•----- ---------------••---------------•••-----•--•---------•-----••--•-••...--•------•---- ------------ --------------•-•,
........................ ....................
of Repairs or Alterations—Answer when a lic ble............ A.1 .F!�f't_........ lT. ..___�.G..._./:_
U P c� PP -• - f {-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TILTH.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Cert sate of Compliance has been ' by the boar f health.
Si Signed
- - -- . -- �----- ................
g �y
Application Approved BY --..._....._ ..a.. /�'.. ��.... ...._..
....................................... .........._.
Date
Application Disapproved for the following reasons-------------------------------------------------- ..............................................................
...................................................................................................................................--------------------------•--•--•-----------...-••-•---•....._------
"rl 1 Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTSQ
BOARD OF HEALTH .
................. ................OF................................-......
Appliration for Bigpas al Warkii Tumtrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: (�
Ali J t U�lf��n Jr
f/�
..............................................•---------------•-•-......-•------"-"------....... '....--"•-•-----......._..............._....._......,------'•"----'-...........................
1,4
1 �Locatio A;,dress or Lot No....... .....!/){r ................. !L 11 4LK.---•--............................ ..........--............................. ................---
/�A O/Wner Address
a -•••--.lam--..-.-#.n......-. /. �/_f r1 l--------------------------------------
Installer _Address
of Building
a TypeDwelling—No. of Bedrooms...................--__--.----_-----------Expansion Attic ( ) Size Lot-Garbag Grinderq feet
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4 Other fixtures ..--...
W Design Flow............................................gallons per person per day. Total daily flow--...........-_............................--gallons.
WSeptic Tank—Liquid capacityJ.'Y ...gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—.\Io..................... Width.................... Total Length.................... Total leaching area----_._--._---._.-__sq. ft.
Seepage Pit Nb-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................--.. Depth to ground water....----...........----.
P�4 Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water..--....................
....................................................................................................................•------------------•----•-----....•..--•--
04•
Descriptionof Soil.......................................................................................................................................................................
W
U --------------------•----•------••••....----•------••--••--•--------------•--------•--------...----........_..------••'-'--------•-------•--•-•-------•---••-•---•-•-•-•--------------'---•---------•---
W
..........................................................--------------------------------------------•---•------- y
x ------------------------ ,
V N�artyre of Repairs or Alterations—Answer when appli ble.--.....--- . _.e. �1�/C _____-_ �, ____•E.c,�?_ _r X.-----,t�
G._..._..-_.!�_l f�!t_r7N. �°f E?. l�P?......r/fo rr �r l % ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i?_LEI, j of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Cer iiicate of Compliance has been ' s byf the boar -of health.
*� Signed. C ..................................................
--- =�� ..01-
C.
Apphcat>on Approved By ..... �'`.... ... ............... =---------- ---- -------- --------.----------
Date
Application Disapproved for the following reasons:-------•-----------------------------------------------------------------------•------------•-••---•-......_.._
...............•.....------------------. --•----•-•-----...-------•-•--------•-••---------•----....----•••---•'------------•---•--•---------....----------------•----•-•••--•--•----------••...------
Date
PermitNo.. ........................................��� Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEALTH
.....!.....PW. .........OF........ �NSZ A-'( 1 C
...............................................•------
Trrtifiratr of ToutpliFanrr
THIS IS._ O._-CER,TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by--------------- 'r '�")....-•--. - u --------•--•.
C" ':::�--Knstaller
T
at............. ............. ------ =^-------•----------- --- ......--
has been installed in accordance with the provisions of i i ii,L j of The State Sanitary e s described in the
�o
application for Disposal Works Construction Permit No.�._.�.y_._."T._' 1__I._._._._ dated........... ......... ._--..-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM W L N SATISFACTORY. t----
DATE.. ' ......................................... Inspector....L --------•-.....------------•---•--•-•---••-----...........-'---.......
THE COMMONWEALTH OF MASSACHUSETTS
t' BOARD OF HEALTH ®
VJ fV
............................. .. ........�............_.�.....`...�"...'...............................................
l�rv' .................. t'EE. ...
'/��ailan rrmi�
Permission is hereby granted................. .!. ....tom,._ .N �--------------•---.
to ConstW,, or Rkpmr ) an Ind' ' -ual Sewa a Disposal System
r . ¢ L-
Street
as shown on the application for Disposal Works Construction Permit i� `7�_. Dated...........�-'6 X15--_---.....
' r / 4
y\ oard'of Health „1
DATE- >- � ...................... �-
FORM 1255 HOBBS & wARREN�NC, PUBLISHERS �}
SI-24-301
Title V State of MA Inspection Report – Filed with Health Division · Add to a project
Active Request Changes
(/#/explore/request-changes/412658)
Expiration Date
Details
Submitted on Jul 19, 2024 at 8:00 am
Attachments
1 file
Activity Feed
Latest activity on Aug 22, 2024
Applicant
Taylor Court 0
Location
818 SOUTH MAIN STREET, Centerville, MA 02632
Septic Inspection Report Filing Fee
Paid Aug 09, 2024 at 9:11 am
Administrative Review
Completed Aug 09, 2024 at 9:53 am
Health Inspector Review
In Progress
View Edit Workflow
Health Inspector Review
Became active 13 days ago
Active
Assignee
David Stanton
Due date
None
Remove Note • Aug 13, 2024 at 11:25 amDavid Stanton
@Thomas McKean this came in as NFE. I also received an e-mail
about this property as well ( I will forward it to you as well.) NFE is
because owner is looking to determine the number of bedrooms
allowed/designed for. Our records are pretty scarce with several
title V inspections saying it had capacity for 440 GPD down to 220
GPD. Not sure if they should hire a designer to determine the
capacity? You signed off on a septic permit 86-771 for 2 bedrooms
for them to restone the SAS. It appears to be 4 flow diffusors from
the early 1970's with a tank and pump chamber. 1974 a building
permit was approved for 1 bedroom only, but was pending a septic
location, and in 1978 Ed Kelly submitted a septic location. Outside
zone II, WP/AP, however they are in the Estuary protection and the
house is right on the river, the tank appears to be about 50' from the
river (note: Ed Kellys plans showing the septic location are in the
building div files, not Health.)
Remove Note • Aug 21, 2024 at 12:54 pmGandolfi
@David Stanton @Thomas McKean @Kathryn Soto Property owners
stopped by looking for an answer on this property.
Remove Note • Aug 21, 2024 at 1:29 pmThomas McKean
Two bedrooms are listed on the DSCP record- plus one bedroom
approved in 1974. . [Note: Bedrooms counts are not used for NFE
and Failure criteria according to Title 5].
Remove Note • Aug 22, 2024 at 8:30 amDavid Stanton
Thanks @Thomas McKean so do you want me to have him update
his report to a pass, keep it as 2 bedrooms actual and 3 bedroom
design?
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton I have no objections tot wo bedrooms based on the
official records. I also have no objections to three bedrooms
maximum if the SAS has sufficient capacity.
Remove Note • Aug 22, 2024 at 11:36 amThomas McKean
@David Stanton Also, yes it is a "pass,"
Remove Comment • Aug 22, 2024 at 12:00 pmDavid Stanton
Hi Taylor/Michael, the report has been reviewed as well as the old
Building and Health files. The report can be updated and re-
attached in this same inspection number SI 24-301 as a pass. The
design can be changed to 3 bedrooms as they have four flow
diffusors with stone and the property is only in the Estuary
protection which limits it to 3 bedrooms maximum based on the lot
size.
r
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
V�
Property Address
r
Todd Kittredge
Owner Owner's Name /
information is required for every Centerville ✓ Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
i
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms i�A. Inspector Information l#- ( (o94
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites path
Company Address
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal.systems. After conducting this inspection I have determined
that the system:
1. ® Passes
� �-�Nk OF S���'�
2. El Conditionally Passes .�`��� '' 's9''�.
MICHAEL
3. ❑ Needs Further Evaluation by the Local Approving Authority =o; SEARS
No.SI14430 y
4. ❑ Fails Ao o
S I N SP .
nnnnuW
7-20-20
Inspector's 5 ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
c � Commonwealth of Massachusetts
,1P Title 5 Official Inspection Form
.IIn Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in 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):
Further r f 3) urt er Evaluation is Required by the Board Health:o
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
k tiI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
To be considered a large system the system must serve a facility with a
5) Large Systems: g y y y �
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u � 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
2018- 53000 gal
Water meter readings, if available (last 2 years usage(gpd)): 2019- 53000 gal
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
........... 818 South Main st
V�
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
c Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� 818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 60"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� 818 South Main st
u—
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 50"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
24"
2"
Scum thickness
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle wall with cover at 8" under bricks, outlet cover 50" under bricks
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<`I; Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
u
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No"
Alarms in working order: ® Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
1000 gal pump chamber at 4' below grade with cover at 1'below grade
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
k_ I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
V
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 4 flow diffusers no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
u
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ti, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is
required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t
0 �
F�oh� A 1
10
a0
a�
C
0
0
y
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
f
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is required for every Centerville Ma. 02632 7-20-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15'
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:
Gaheerty & Miller Model 12-16-94
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main st
Property Address
Todd Kittredge
Owner Owner's Name
information is Centerville Ma. 02632 7-20-20
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Gr4dC
y�
PWam of SAS _ t5•
ll�
6r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r4 � Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: /
When filling out A. General Information ��--
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key: Capewide Enterprises,LLC
Company Name
rL P.O.Box 763
Company Address
Centerville Ma 02632
City/Town. State Zip Code
(505)428-4028
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the;4
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 t6-Section915.340,of
Title 5 (310 CMR 15.000). The system: _ '
® Passes c 7:`Z
❑ Conditionally Passes ❑ Fails
�i
❑ Needs Further Evaluation by the Local Approving AuthorityCD r
20/02/07
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
:pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection,
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
C) Further.Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,'safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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
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.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
` D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 1-5.303, 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.
818 s.main•.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
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 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 maintenance f proper a ce o 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)]
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is Centerville. Ma 02632 02/02/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
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
000
,:22
Water meter readings, if available (last 2 years usage (gpd)): 2002005: 2, 0
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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:
Last date of occupancy/use: Date
Other(describe):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1986
Were sewage odors detected when arriving at the site? ❑ Yes ® No
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
6"
Depth below grade: 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.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
4'
Depth below grade: 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: 8'6"X4'10"X57"
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 0
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Measured
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
onw ea
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2-3 years.lnlet and outlet tees are in place.Tank is structurally sound.No
evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 818 South Main St.
Property Address .
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑.No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
L_
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is structurally sound.Pump and alarm are working properly.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4 Flowdiffusers
❑ 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.):
Sandy soil.Flowdiffusers were dry at time of inspection.No signs of hydraulic failure.Vegetation
appears normal.
818 s.main-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow , ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
c
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
t9'
�6' I o t
CG
818 s.main•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 818 South Main St.
Property Address
Lawrence Siscoe
Owner Owner's Name
information is required for Centerville Ma 02632 02/02/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to ground water: 15'
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:
As-Built Card.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller Model 12/16/94 Ground Water Elevations Above Sea Level.Used:Observation
Well Data June 1992 Used:Technical Bullettin 92-000-1 Plate#2 Annual ranges of ground water
elevations January 1992.
818 s.main•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
l
0 fs
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL, �f<PAk 121
DEPARTMENT OF ENVIRONMENTAL ,(�r �TECT ON V*
ONE WINTER STREET. BOSTON. MA 02108 617-2 15'50000
CT F®
WILLIAM F.WELDTy�oTeg9iy� 1�'q UDY CORE
Governor /" 1 494t 4% Secretary
ARGEO PAUL CELLUCCI ID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO 5 Commissioner
PART A g
CERTIFICATION
Property Address: 81 8 S Main St, Centerville Address of Owner: Robert Baker
Date of Inspection: 16^C 9 17 (If different)
Name of Inspector: Wm E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Cent-Prvi 1 1 P, MA 02632
Telephone Numbers 50, ^ 7 7 5_R 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
71 Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: : Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The System will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wde Web: http:/twww.magnet.state.ma.us/dep
a�j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: `�y� G 17
B) STEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
" Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
0 broken pipe(s) are replaced
obstruction is removed
C) FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic health, safety and the environment.
1), SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
SYSTEM WILL FAIL UNLESS THE BOARD Of HEALTH (AND PUBLIC WATER SUPPLIER, If APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3 OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Dl STEM FAILS:
You m t indicate ei;,,er "Yes" or "No" as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
t failure.
Yes N
Backup of sewage into facility or system component due to an 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 1/2 day flow.
4;
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LAR E SYSTEM FAILS:
You m st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No v
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Id -7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye No
1_/ _ Pumping information was provided by the owner, occupant, or Board of Health.
t✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal
Y P
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ 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.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
_2
(ravimad 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:� <� lO g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):_A,_p
Laundry connected to system (yes or no): L-5
Seasonal use (yes or no): /�
Water meter readings, if available (last two (2) year usage (gpd): 1995 — 89,000 gals
Sump Pump (yes or no): d-0 1 9 9 6 - 66 , 000 gals
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type f establishment:
Design low: gallons/day
Grease rap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available.
Last lof
of occupancy:
OTHDescribe)
Last occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source f information:
System pumped as part of inspection: (yes or no)_A-
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
1-1 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)
1/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: j';'64
b
Sewage odors detected when arriving at the site: (yes or no)Ard
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: ��r��� 7
BU ING SEWER: /
(local on site plan)
Depth low grade:
Materia of construction: _cast iron _40 PVC _other (explain)
Dista a from private water supply well or suction line
Diamet r
Comm ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction: oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: / -I-- Ae
L
Sludge depth: 5'—S
Distance from top of sludge to bottom of outlet tee or baffle:3rt
Scum thickness:/— 3 , r i
Distance from top of scum to top of outlet tee or baffle: t
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: tj gf
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level-inn relation to outlet invert, structural
integrity, evidence of leakage, etc.) j-�+— �.� ��1 a� 7 4
GRE SE TRAP:
(locate on site plan)
Depth b low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ons:
Scum ickness:
Dista ce from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Commen s:
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: %8^�
T HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(lo eon site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dim sions:
Capad gallons
Design low: gallons/day
Alarm I vel: Alarm in working order_Yes; _ No
Date of previous pumping:
Comm nts:
(cond' ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: (/
(locate on site plan)
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, etc.)_=j
PUMP CHAMBER:`^
(locate on site plan)
Pumps in working order: (Yes or No) fZ-s
Alarms in working order (Yes or No)
Comments: T— l �� / O
(note condition of pump chamber, condition of pumps and appurtenances, etc.). /G>4-� L.,',�/ + 67 6 csc�J
A.
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(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, number:_
leaching chambers, number.
leaching galleries, number:
leaching trenches, number,Iength:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition oil, signs of hydraulic failure, level of p ndin , condition of vegetation, etc.) s
a C ,-
� a
CE POOLS: _
(loca on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimens ns of cesspool:
Materia s of construction:
Indicat' n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Com ents:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI
(loca on site plan)
erials of construction: Dimensions:
De p h of solids-
Com ents:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection: Je �G�q�
1 ✓
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks 1L
locate all wells within 100' (Locate where public water supply comes into house)
u/
0
1 Q
1
(revised 04/25/97) Page 9 of 10
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 818 S Main St, Centerville
Owner: Baker
Date of Inspection:
Depth to Groundwater/A Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V/Observation of Site (Abutting property, observation hole, basement sump etc.)
V Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
(/ Use USGS Data
Describe in
our own words how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
SSOR'S MAP NO. / 93' PARCEL S�
LUO;�:�► TION SEWAGE PERMIT NO.
M? SO m,4;,-
L
VI �, AGE
I N S T A LLER'S NAME A ADDRESS
g-,5510.�
71 ,0 c olfe If
S UI�` DE R OR OWNER
�1
�T 9.4 kEA
DATE PER_ IT ISSUED
DATE COMPLIANCE ISSUED
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DATE PERMIT ISSUED �y7�
DATE COMPLIANCE ISSUED &�,
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THE COMMONWEALTH OF MASSACHUSETTS _._
BOARD OF HEALTH
..........................................OF..........................................-----................----...---.................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...........,?/Ja
..................r.�f �9 ....�?_.. .......................•............--.......--.-----.---.--...............•.......-•.............
/ �1 ocatio d,{iress or Lot No.
Ow�er Address
a �f.!e�e!1_...._.1l:._L✓f/!_!z- ...................................
Installer Address
d Type of Building Size Lot..._ ____________________Sq. feet
U Dwelling—No. of Bedrooms.................... . Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity_ ...gallons Length................ Width................ Diameter................ Depth__..-_____---_-.
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___-___-----------sq. ft.
Seepage Pit No..................... Diameter..............._.--- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
f
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
a -•••-----••---------------------•-------------•-•---------------------•-------• -------------
--------------------------------
0 Description of Soil............................................
x
U •-------------------------------------------------------------------------------------------------------------------------------------...........................................................
W ---------•----- ---------------••---------------•••-----•--•---------•-----••--•-••...--•------•---- ------------ --------------•-•,
........................ ....................
of Repairs or Alterations—Answer when a lic ble............ A.1 .F!�f't_........ lT. ..___�.G..._./:_
U P c� PP -• - f {-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TILTH.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Cert sate of Compliance has been ' by the boar f health.
Si Signed
- - -- . -- �----- ................
g �y
Application Approved BY --..._....._ ..a.. /�'.. ��.... ...._..
....................................... .........._.
Date
Application Disapproved for the following reasons-------------------------------------------------- ..............................................................
...................................................................................................................................--------------------------•--•--•-----------...-••-•---•....._------
"rl 1 Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTSQ
BOARD OF HEALTH .
................. ................OF................................-......
Appliration for Bigpas al Warkii Tumtrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: (�
Ali J t U�lf��n Jr
f/�
..............................................•---------------•-•-......-•------"-"------....... '....--"•-•-----......._..............._....._......,------'•"----'-...........................
1,4
1 �Locatio A;,dress or Lot No....... .....!/){r ................. !L 11 4LK.---•--............................ ..........--............................. ................---
/�A O/Wner Address
a -•••--.lam--..-.-#.n......-. /. �/_f r1 l--------------------------------------
Installer _Address
of Building
a TypeDwelling—No. of Bedrooms...................--__--.----_-----------Expansion Attic ( ) Size Lot-Garbag Grinderq feet
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4 Other fixtures ..--...
W Design Flow............................................gallons per person per day. Total daily flow--...........-_............................--gallons.
WSeptic Tank—Liquid capacityJ.'Y ...gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—.\Io..................... Width.................... Total Length.................... Total leaching area----_._--._---._.-__sq. ft.
Seepage Pit Nb-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................--.. Depth to ground water....----...........----.
P�4 Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water..--....................
....................................................................................................................•------------------•----•-----....•..--•--
04•
Descriptionof Soil.......................................................................................................................................................................
W
U --------------------•----•------••••....----•------••--••--•--------------•--------•--------...----........_..------••'-'--------•-------•--•-•-------•---••-•---•-•-•-•--------------'---•---------•---
W
..........................................................--------------------------------------------•---•------- y
x ------------------------ ,
V N�artyre of Repairs or Alterations—Answer when appli ble.--.....--- . _.e. �1�/C _____-_ �, ____•E.c,�?_ _r X.-----,t�
G._..._..-_.!�_l f�!t_r7N. �°f E?. l�P?......r/fo rr �r l % ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i?_LEI, j of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Cer iiicate of Compliance has been ' s byf the boar -of health.
*� Signed. C ..................................................
--- =�� ..01-
C.
Apphcat>on Approved By ..... �'`.... ... ............... =---------- ---- -------- --------.----------
Date
Application Disapproved for the following reasons:-------•-----------------------------------------------------------------------•------------•-••---•-......_.._
...............•.....------------------. --•----•-•-----...-------•-•--------•-••---------•----....----•••---•'------------•---•--•---------....----------------•----•-•••--•--•----------••...------
Date
PermitNo.. ........................................��� Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
{ BOARD OF HEALTH
.....!.....PW. .........OF........ �NSZ A-'( 1 C
...............................................•------
Trrtifiratr of ToutpliFanrr
THIS IS._ O._-CER,TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
by--------------- 'r '�")....-•--. - u --------•--•.
C" ':::�--Knstaller
T
at............. ............. ------ =^-------•----------- --- ......--
has been installed in accordance with the provisions of i i ii,L j of The State Sanitary e s described in the
�o
application for Disposal Works Construction Permit No.�._.�.y_._."T._' 1__I._._._._ dated........... ......... ._--..-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM W L N SATISFACTORY. t----
DATE.. ' ......................................... Inspector....L --------•-.....------------•---•--•-•---••-----...........-'---.......
THE COMMONWEALTH OF MASSACHUSETTS
t' BOARD OF HEALTH ®
VJ fV
............................. .. ........�............_.�.....`...�"...'...............................................
l�rv' .................. t'EE. ...
'/��ailan rrmi�
Permission is hereby granted................. .!. ....tom,._ .N �--------------•---.
to ConstW,, or Rkpmr ) an Ind' ' -ual Sewa a Disposal System
r . ¢ L-
Street
as shown on the application for Disposal Works Construction Permit i� `7�_. Dated...........�-'6 X15--_---.....
' r / 4
y\ oard'of Health „1
DATE- >- � ...................... �-
FORM 1255 HOBBS & wARREN�NC, PUBLISHERS �}