HomeMy WebLinkAbout0047 FOXGLOVE ROAD - Health y-47 Foxglove Road
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Marston Mills
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Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville MM Ma 02632 11/21/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 614r /6Otsal'
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
Co pang A Lane
� Company Address
Centerville Ma 02632
City/Town State Zip Code
few
774-2484850 smjonestitle5@gmail.com, SI4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
11/21/2020
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 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
Title 5 Official Inspection Form
I.- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 47 Foxglove Road
Property Address
Robert Pauly
Owner Owners Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 47 Foxglove Rd Centerville is served by a Title V septic system consisting of
a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system
was found to be in proper working condition at the time of inspection this report does not guarantee
future performance under similar or increased usage.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Citylrown 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 obstructedpipe(s)or due to a broken settled or uneven distribution x. m box. System well
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
obstruction is removed Y n N El 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):
3) 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�e
47 Foxglove Road t
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that 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.
El 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
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
t5insp.doc-rev.70612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a 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 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
rP Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Foxglove Road
Property Acdress
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes, No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
-� 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2018 = 19,000 total = 52 gpd 2019= 39,000 total = 107 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
k
V��w
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments
�
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
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:
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
r
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
e
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ 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:
Original system for house built 1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
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 in good condition, no leakage, vented through roof.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Foxglove Road
Property Acdress
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depths below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was pumped recently and should be done again every 2 years for proper maintenance. Water
level was even with outlet invert. Tank was not leaking and was structurally sound. Inlet and outlet
tees inatct and in good condition. Inlet cover is on a riser.
t5insp.doc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
(e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Foxg'ove Road
Property Address
Robert Pauly
Owner Owner's Name
information is requi d for every Centervi.le Ma 02632 11/21/2020
page.re City1rown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Dept-i 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 ievels 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of 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
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
h-20 distribution box was level and in good condition with no rot. Water level was even with outlet
invert with no signs of past backup. Steel cover is on riser to grade.
t5insp.doc-rev.M60018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(� 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centervilfe Ma 02632 11/21/2020
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.):
*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.
® Teaching pits number: 1x1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- - 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
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.):
s.a.s, consists of a 1000 gallon precast leach pit with 1'stone. leach pit was found with approx 3'
standing water at time of inspection with a stain line only 2" higher. Pit was inspected with mirror and
light. Pit has steel ring and cover on riser.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityfrown 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
o l
A-t Z 7 `6
�i2 Z 9 6
A 3 36
g3
/+ Y
t3y tiZ
l5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M V 47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Lmn.VpAoc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
r
Commonwealth of Massachusetts
t, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Foxglove Road
Property Address
Robert Pauly
Owner Owner's Name
information is required for every Centerville Ma 02632 11/21/2020
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 18 of 18
r
Commonwealth of Massachusetts
' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fotrtn-Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John 8 Stephen Viveiros a-a
Owner Owners Name
information is a
required for every Cefttewi° MA 02632 2-23-17
page. CityrTown State Zip Code Date of Inspection t-
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms CC/ ``%���tntillurrry/r///
on the computer, Jl ���(P/ ��v� SF1OFd?q V,/,
�. rcf�-•.. ., �.
use only the tab ��
key to move your t Inspector: p�'r' ,yG
cursor-do not a-: JAMES
James D.Sears _- rn=
use the return Name of Inspector
key. N = 3 rn a
Ca ewide Enterprises *�•,o� �o:
Q Company Name
153 Commercial Street 4ggrsrINS
pG������\
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15,340 of
Title 5 (310 CMR 15.000), The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ weeds Further Evaluation by the Local Approving Authority
2-23-17
Spector s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DER)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 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,
t5ins.Uoc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�V VS
8t abed 6666bE5805 ueW uol�adsui ayl wlr 5,7:96 L60Z b0 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Vveiros
Owner Owners Name
information Is
required for every Centerville MA 02632 2_23-17
page. Cltyrrown State Zip Code Date of Inspection
B. Certification (cont)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal, Tank D Box and pit
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes', "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins.doc•rev.6116 Tille 5 Official Inspection Form Subsulace se•Mape Disposal System•Page 2 of 17
66 a6ed 6666K9809 ueW uoicadsuI a41 wir 9t,:9l, LIOZ t70 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Fax Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information Is
required
wired for every Centerville MA 02632 . 2-23-17
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s), The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.&c rev.W 6 6Title 5 OfrrGal Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
OZ a5ed 6666bE9909 ueW uoloadsul @41 wir 9b:9l, LI.OZ b0 JeW
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owners Name
information is
required for every Centerville MA 02632 2-23-17
page. diyfTown State Zip Code Date of Inspection
R Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, If any)
determines that the system is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all Inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Ej ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth injEjj=is less than 6"below invert or available volume is less
than %day flow pl r
l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sew
age Disposal System•Page 4 of 17
2 a5ed 61.66b£S809 ueW uol:)adsuI a41 wlr &9l, L60Z t70 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface ace Sewage Disposal System Form Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owners Name
information is Centerville
required for eve MA 02632 2-23-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis,performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,0009pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 16.303, 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 I I of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6!'6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•PKe 5 of 17
ZZ a5ed 61,66bE5809 uew imoadsul aLLL wlr L,v:96 Ll,0Z t,0 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is
required for every Centerville MA 02632 2-23-17
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [31D CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 god x#of bedrooms): 330
t5lns.00c-rev.6116 Title 5 Official In"clion Form:Subsurface Sewage Dieposal System-Page 6 of 17
£Z a5ed 6166b£5809 ueW umDadsuI a41 wir 8t,:96 LI.OZ t70 JeW
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John & Stephen Viveiros
Owner Owners Name
information is
required for every Centerville MA 02632 2-23-17
page. GNy/Town State Zip Code
Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and pit
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2015-35,O000al
Detail: 2016-37,OOOGal
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc rev.6116 Title 5 Ofrclal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
bZ a5ed 61,66b£5805 ueW jmDadsul ayl wlr 8�,:91• L 60Z b0 JeW
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is Centerville
required for every MA 02632 2-23-17
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
Gene
ral Information
Pumping Records:
Source of information: 2015
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/A Item ative 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 11A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
tsins.doc•rev.0116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
5Z a5ed 61.66b£5805 uew uoj�adsuI aqi wlr g�;gt L602 b0; j3k-
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information
fired a every
Centerville
re wired for eve MA 02632 2-23-17
page. Cityfrown State Zip Code Date of Inspection
D. System Information (Cont.)
Approximate age of all components,date installed (if known)and source of information:
1978 2-2017 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 22"
feet
Material of construction:
❑ cast iron ®40 PVC ®other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40&SCH -20.
Septic Tank(locate on site plan):
Depth below grade: 1'reet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Parecast H-10
Sludge depth:
1"
15ins.doc-rev.6l16 Tillie 5 official Inspection Form:Subsutiace Sewage Disposal System•Page 9 of 17
9Z abed 6666ti£5809 ueW JoioadsuI eqj wIf 6t,:91• L60Z V0 Jew
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Uf
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is
required for every Centerville MA 02632 2-23-17
page. CityrrDwn State ZipCode Date oflns on
pecU
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness �-
Distance from top of scum to top of outlet tee or baffle 12
Distance from bottom of scum to bottom of outlet tee or baffle 17
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and covers at 1' below grade. In and outlet baffles. No sign of leakage
or overloading.
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
t5lns.doc-rev.6116 Tito 5 Official Inspection Form:Subsurface Sewage Disposal System-PaN 10 of 17
LZ a5ed 6666�£5809 ueW JaloadsuI @41 WIF W91• L1,2 ti0 JeW
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Fax Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is required for every Centerville MA 02632 2-23-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins.doc-rev.6116 Title 5 Official Inspection Form Subsurface Sewage Oiwosal System-Page 11 of 17
8Z a5ed 6666b£S809 ueW uopadsul aqj wlf 6t,:96 L60Z t70 JeW
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information Is
required for every Centerville MA 02632 2-23-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (Cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
C Box is 22" Below Grade wlone line out. Steel cover at grade in black top drive. 2-2017 New H-2o
D Box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
i
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
tsins.doc•rev.6N6 Title 5 Official Inspection;:arm;subsuriace sewage Disposal system•Page 12 of 17
6Z a5ed 6 666b£5805 ueW im3adsui aLL wir 05g i, L 60Z to JeW
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" 47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is required for every Centerville MA 02632 2-23-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit. Pit at 18" below grade w/steel cover at grade. Wall's clean no
high stain line. Steel cover at grade in black top drive.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6116 Tine 5 offew Inspection Forth:SubsuAace Sewage Disposal System-Page 13 of U
0£ a5ed 6666bE9805 ueW jolDadsuI ayl wlf 09:96 L60Z b0 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owner's Name
information is required for every Centerville MA 02632 2-23-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction.
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15 ns.doc-rev.8118 Title b Official Inspection Form:Subsurface Sewage Disposal System-Page 14 gf 97
l,E abed 6666b£5805 ueW jol3adsui ate wlr 0g:96 L60Z vo jeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owners Name
information is
required for every
very Centerville MA 02632 2-23-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
r
i
3 3-9 ieev�s
= Q� 0
t5ins.doc rev.6A6 Title 5 ofricial Inspection Fcrm:Subsurface Sewage Disposal System•Page 16 of 17
Z£ a5ed 6666b£9809 uew jolDedsui aU wir 05:91, L60Z V.l Jew
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface
Sewage Disposal System Form Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Vveiros
Owner Owner's Name
information is
required for every Centerville MA 02632 2-23-17
page. CitylTown State Zip Code Date of Ins pection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells a
N
Est'mated depth t high ground water: 13'
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: 7-9-80
Date
❑ Observed site (abutting property/observation hale within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H.on Design plan 7-9-80 17' no G.W.. Bottom of pit at T-6" below grade. Bottom of pit at 51-6"
above T.H. Depth,
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins.doc-rev.W16 Title 5 ONicial Inspection Form Subsurface Sewage Disposal System-page 16 of 17
££ a6ed 6666b£5809 ueW uolcadsul aq wlr 65:96 L60Z b0 JeW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
47 Fox Glove Road
Property Address
John &Stephen Viveiros
Owner Owners Name
information is
required for every Centerville MA 02632 2-23-17
page. City(rown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6116 Title 5 Official Inspection Fcrm:Subsurface Sewage Disposal System•Page 17 of 17
b£ a5ed 6666t£9809 ueW jcgDadsuI ayl wir I•ggl, L60Z to ueH
No t�/G Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
9pplitation for Bisposal 6pstem Construttiun Permit
Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 4-1 EOXC.L0Ve: P10 Owner's Name,Address and Tel.No.
�YG�Et�`iJ i/1�E/F.vS
Assessor's Map/Parcel r 13v 004 ke-141-1 qZ F'Z>XC;[00 RD �i �
Installer's Name,Address,and Tel.No. 561-W7 7-9W"Z Designer's Name,Address,and Tel.No.
C AghSurirjG ENzbMeuu54F,'&_ /�
Type of Building:
Dwelling No.of Bedrooms 1A Lot Size sq.ft. Garbage Grinder( )
Other Type of Building (SUTi �No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) T&j$(&L-t- A)b?jt j I*-a® ID 80K w rT&t M95RN
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date rO�l
Application Approved by Date 1 )
II Application Disapproved by Date
for the following reasons
Permit No. t 7 '® le Date Issued
No l '`�� �`�' �V Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for Disposal 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 41 FOX C;LCX!5 RQ0 Owner's Name,Address and Tel.No.
5-rcerteij Vi Jcmos
Assessor's Map/Parcel ( 13D 014 4-7 FOXe4QUC AD CZArrt3 CC G7
Installer's Name,Address,and Tel.No.56%--4-7 T—918 7 1 Designer's Name,Address,and Tel.No.
C°,AV6U.c7;?C EnJTM7,PWA-S4 �&C , F/�
1<3 S'1— l�IA�t�D N
Type of Building:
fff Dwelling No.of Bedrooms IA Lot Size sq.ft. Garbage Grinder( )
Other Type of Building IRF,,S t Z) l c No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -:rl)15 TA L.(.. lU cRAJ 14—a) D—QOK to rTa i�oc—_A-.
Date last inspected:
Agreement:
— The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign Date .Z— l
Application Approved by Date ��7 A
- Application Disapproved by " Date
` for the following reasons
Permit No. �" Q (� lP Date Issued o`2 J l 7 /1"7
---------------------------------------------------------------------------------------------------------------------------------------
1 THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(y) Upgraded( )
Abandoned( )by CAP&W(M 50T'6 � jS65
at 417 F6?X�,—' L0l)E 1Z.0 0,I V l(_,L>!5 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Noc/��`�6 dated
Installer (2APGL0t1)1=_ &)T6)9A4SS0 Designer NIA
#bedrooms 1 ,� Approved design flow A and
The issuance of this permits all not be construed as a guarantee that the system will f^unct d'on as esigned.
Date Z 1 i Inspector
--------
No. 1�.� �� L J Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair(Y) i Upgrade( ) Abandon( )
System located at �7 .p7o U !k G—La
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must b�completed within three years of the date of this permit.
Date 171 Approved by —��`�
r
Rol
ga lo..�l 7...... Fxs......�k................
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR OF HEALTH
[�J............OF. - --�`�V V�
,� r �irathin for Dispnsa1 Workii Tonstrnstinn ramit
Application is hereby made for a Permit to Construct V\) or Repair ( . ) an Individual Sewage Disposal .
S sy tgsn ats.. ...1 cJ - 11�[_ -= .....:..............
�ocati dress or I.ot No.
C0-lvl wl Qr...4�� ,� i.u4 ...
W ................•-- _J%-• •••---••--- •r.e -•--- ------.....: ----•...-•-------------.......----------...---
.........S.
j Owner Address
�..P. :2 ,......
Installer Address
Type of Building Size Lot___ZGj Q L(-....Sq. feet r
Dwelling—No. of Bedrooms................ ......................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fi tur •-- --------------------------.....------. r
W Design Flow................ .......................... per person per lay. Total flail ,,flow._._........___....._v_._ __..___..__. lons�
P q P Y g g ------- Diameter...... Depth. .. .
W Septic Tank—Liquid ca acit �? .. allons Len th_� ..�. Width _' ._...
x Disposal Trench—No. .................... Width....r....._......... Total Length___........._p......Total leaching area....................sq. ft.
Seepage Pit No.........I........... Diameter....... ......... Depth below inlet..... .___....... Total leaching area.._4...O..sq. ft.
Z Other Distribution box Dosing tank ( ) A
Percolation Test Results Performed by__W.�_ /`ti__ ..................... Date_._ ..... 1..::..�.._._._...__..
W
Test Pit No. 1.-�,�-•.. _.minutes per inch Depth kf�Test Pit------- ....... Depth to ground water__,CJr9 __-1
fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........
a.
O 1 1 r-•--•------..
LZ �� f
Description of Soil '� ... �ua � .......... a"� j E. l.3Yn..... ` P-_----•-••----
x
W
== --------------------------------
•.......
•-----------------
•-------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------------------------------------•-------------------------------•----•------•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee • e b dof hea..l.t.
Signe ........... ........... ...�z -.1130......
s
ApplicationApproved BY---.... -•---------------------------•---•-------......-•-•--•--------------...-..----.. ....................Date..............
Date
Application Disapproved for he following reasons:---•-•----------------•----•---------------------------------•-----------------•------..._...•----......._.._...
-•-•-•------••-•-------------•--•-•----•/-•-----...-•-------••-•----------------••-•--------•-•------••----•-••••-•...--------•-•-••••--------------•---------••--••••-------•---•-------•---•-----------
Permit No.....( ................................................. Issued Issued....._:.��:5�:7'lJ....-.....Dau --
Date
A
A
Je)
-7
No.......... ....... Fim..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR%OF HEALTH
-------------OF............
..................................................
W,
"V Appliration for Bispoiinl Works Tonstrurtion Vrr Mff
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
YLL.5 OT-i( I It,b Utz,"
.......................................... ....................... ...................................................
ocat I
C) or Lot No.
.. ............
...........!��----- ...........................L�.... ..................... .................................................................................................
Owner Address
..........
Installer
Address
Type of Building Size Lot....t.... -----Sq. feet
Dwelling—No. of Bedrooms...............;.�)......................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ...................................................................................................... 77
-------------------
Design Flow................. . .....................gallons per person per day. Tota�,daily,,flow........... .....alon
...... ---------------- sh
Septic Tank—Liquid capacity!(y91..gallons Length.?..... . .__6
.. ..... Width__-�'�..... Diameter.__....... --- Depth.4..........
Disposal Trench—No..................... Width.........._.___..... Total Length__.........._._.... Total leaching area....................sq. f t.
Seepage Pit No....._._.1........... Diameter.......9.......... Depth' below.,inlet....411.... Total leaching area.2 ....sq. f t.
Z Other Distribution box (i_< Dosing tank
Percolation Test Results Performed by_�A) ................................................... Date..... 9'
............................
Test Pit No. 1.4....�=._minutes per inch DepthOof Test Pit...... Depth to ground water..<3.V' 3
V - ------- ---
1:74 Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water___......_...._....._...
pit..................................................................................
...............................................................
0 Description of Soil....0_1.3.........Lc,y+-AA... ........ ................. ....... ................
-----------------------*-*-**-------- -----------------------*---------**,*-*---------*----------------------------*"---------------*-------------- ------ --------
.....................................t...............................................I..................I........................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedesc ib d I di idu I Sewage i posal System in accordpin with
a rd __Lj ivi t T) V. Ce
the provisions of r[ITTIE 5 of the State Sanitary MA— �j nder ' ed 9 o placlgg(wn
operation until a Certificate of Compliance has bee boa I V
.010, rpl*�
Signedi 7---------------------------------
ate
ApplicationApproved ............ ......,By....... V D... ........................................................... ........................................
Date
Application Disapproved for de following reasons:............................................................................................ -..............
................................................................................................................................................ .............................
6 q 7- , Date
PermitNo......................................................... Issued........................................................
Date
xaTHf COMMONWEALTH O'F MA�SACHUSETTS
BOARD OF HEALTH
t
/. ................OF............ ............................................................
p. -27-uXrrVfiratr of Toutpliatta
THIS IS TO CERTIFY,'That the Individual Sewage Disposal System constructed or Repaired
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
4..........................................
at..............................................................0
- -
----------
----------*------------------ -------------
has been installed in accordance I T LE ' . i,�
dance with the provisions of T 57oi The State Sanitary Code a74scribed in the
application for Disposal Works:Construction Permit N6:t, .............. dated...........................................
--------- .....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.`
DATE........................................................
..... Inspector....................1.1e........................................................
P,l
THE COMMONWEALTH OF.MASSACHUSETTS
17 aOARD O�?01 jhd
No......................... ..........................................OF...............................i.....................................................
P -2 FEE........................
Raposat orka onotrurtion pamit
Permissionis j ereby granted..g',,',, ............. ---------- ...........................................................
to Construct -ror Repa/6 an �I-hdividual.Sewage Disposal System
. 6- � z �iz��-, — -i�4;_,kv-� --------------------------------------
at No.....................*................................. ...........
..................
as shown ori thd-appjkation for
Disposal Works Construction Permit No..................... ated..........................................
.......................................................................................................
]Board of Health
DATE..................*;*------------ -----------
FORM 1255 HOBPS & WARREN. INC, LLSH ERS
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