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Home My WebLink About0083 NORTH PRECINCT ROAD - Health 83 Northr Precinct Road Marstons Mills A = 148 - 134 Commonwealth of Massachusetts � � 13� 0-tv— 3 Title 5 Official Inspection Form r�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name / information is required for every Marstons Mills N MA 02648 8-20-20 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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 8-20-20 `n or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 s Commonwealth of Massachusetts Eli Title 5 Official Inspection Form C-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" 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 El ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora i11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 El ❑ 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): 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 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 C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is Marstons Mills MA 02648 8-20-20 required for every 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. I . ❑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 Commonwealth of Massachusetts Title 5 Official Inspection Form �-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 '/z 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. 0 ® 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Ir' wa Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a " 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for an 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? ® ❑ Wasthe 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 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form I61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow.Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 0 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: Sump pump? ❑ Yes ® No Last date of occupancy: 2020 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w"' I6'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 page. CityrTown 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: 2016 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"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.): Good.condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form _. i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 6"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 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 f � Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 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.): Good condition with water at working level and no sign of back-up from field. t5insp.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 _. ' 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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.): * 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: 2-500's ❑ 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 Commonwealth of Massachusetts �i Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r < r ls, 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is Marstons Mills MA 02648 8-20-20 required for every 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. 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 w Title 5 Official Inspection Form 1'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 C L .5 ' 3 - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,3 83 North Precinct Rd Property Address Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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: 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >` 83 North Precinct Rd Property Address . Jessica Witter Owner Owner's Name information is required for every Marstons Mills MA 02648 8-20-20 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Vffl ACM tylip DunmBRORCiWI tt' bAaimodim . tomitetotieott °tif FaGit :wrIN 1ili aft.. tI{sezisr .oas�e.orZ�t1`::�::-.:; � .,: � •.fit $dg of. et4. d'Ige14Y:;exist E14J a � 3 - ly ' A _ TOWN OF BARNSTABLE LOCATIONa'1 a,;(jk?Q" SEWAGE# e 1 06—C60 VILLAGE ALf. a A',JJ% ASSESSOR'S MAP&PARCEL jt4bj3 g INSTALLER'S NAME&PHONE.NO., n^c ,-, SEPTIC TANK CAPACITY CjiIS1 i=V: LEACHING FACILITY: (type) (size) M X 4.B3 A NO.OF BEDROOMS 9, P r,Lkd OWNER C,S PERMIT DATE: -aci•-l(, COMPLIANCE DATE: .Z IT- I G !� Separation Distance Between the: Not - G=:t`T(>'Ah' O Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -J?eCC Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY `1 �j�C��lV <C4 Ao - 2-3 1 - 3i - qu - IG 'SO Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic Mstems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Cemetyifl8 /1/� MA 02632 Janus 27 2016 required for every January , �,.. page. City/Town State Zip Code Date of Inspection e W W Inspection results must be submitted on this form. Inspection forms may not be altered irr any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. . Eco-Tech Rapid Response p P Company ran P Y Name 155 George Ryder Road South Company Address Chatham MA 02633 CitylTown State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage'disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs F au S` the Local Approving Authority o DAVID YGs o D. U C UGHANO 0 9 January 27, 2016 Inspector's Sig%ins - F �� Date G/STER The systems I a mit a copy of this inspection report to the Approving Authority (Board of Health or DEP) wit 0 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. t5ins•3/13 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 E 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 5 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address 4 Emilios and Anastasia Rigas Owner r,w Owner's Name requirati0.:e Centerville MA 02632 January 27, 2016 required fo��every page. `4 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. f f *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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every ry page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) I ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 1 B) System Conditionally Passes (cont.): 1 I ❑ 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): k ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °LM 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded El ® q or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 83 North Precinct Road -Assessor's ID: 148-134 Go-to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27 2016 required for every ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to'a surface water supply. ❑ ® Any portion of a cesspool or privy Is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary.to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 115,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is required for every Centerville MA 02632 January 27, 2016 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? Z ❑ 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 (assessor) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is rY Centerville MA 02632 January 27 2016 required for every , page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 180 gpd 9 ( Y 9 (gpd)): Detail: 2015: 74,000 gallons 2014: 58,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27 2016 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 40 years. Design plan for original dwelling was dated April 22, 1976 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): 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: 8.5 x 5 x 6-1000 gallon Sludge depth: not determined t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address I Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every ry page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle not determined Scum thickness not determined Distance from top of scum to top of outlet tee or baffle not determinedin Distance from bottom of scum to bottom of outlet tee or baffle not determined How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was not opened because conclusive evidence of failure was seen at leach pit. Tank should be pumped dry at time of system repair and examined for structural integrity if it is to be reused. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every rY page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech..us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27 2016 required for every y 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 not evaluated Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): III * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27 2016 required for every y page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: leaching❑ eac number, length: 99 ❑ 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 pit was uncovered and found to be full with have heavy effluent contact staining. 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 A Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17, , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every ry page. Cityrrown 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 LOC/a° 77OoNN9 —OF SEPTIC COMPONENTS NOT —DISTANCES IN DECIMAL FEET TO y A B C SCALE 1 --- 18 31 2 38 Ib ——— 3 42 25 ——— '' J A 508 364-0894 EMS TWO D WELL§NG THIS SKETCH IS BEST VIEWED IN (93 COLOR FORMAT B C 1000 GALLON SEPTIC TANK DISTRIBUTION BOX i2! Q 3 4, u, z_ LEACH or cr ✓' PIT � Q 3 NOR 11 W PREC §NNCT ROAD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 11 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: Approved design plan on file with the Town shows groundwater was encountered at a depth of 11.5 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 North Precinct Road -Assessor's ID: 148-134 Go to Eco-tech.us for more info on septic systems. Property Address Emilios and Anastasia Rigas Owner Owner's Name information is Centerville MA 02632 January 27, 2016 required for every rY page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 l� 10 .� No. Fee THE COMMONWEALTH OF MASSA HUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �✓� 01ppliLation Dr Misposal Opstem Construction Permit Application forma Permit t s bt( )� eeltW Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. ( ,j-I� d ` j-' Owner's Name,Address,and Tel.No. M W%tvf% Nl,'%)% R l ca% Assessor's Map/Parcel ! Installer's Name,Address,and Tel.No. Designer' ame,Addr s,and el.No. o v R i o wf__ Type of Building: Dwelling No.of Bedrooms `� Lot Size j'],&J(, sq.ft. Garbage Grinder( ) Other Type of Building p S� U�� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ,. gpd Plan Date Number of sheets 9-. Revision Date Title Size of Septic Tank L�[S�'►�`�_�A` Type of S.A.S. aS p C'�� WA S RO Description of Soil Nature of Repairs or Alterations(Answer when applicable) j4StC,A 6��cc.� ��[�p�, C,,jo2 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. igne ' Date Application Approved by Q Date Application Disapproved by Date for the following reasons Permit No. �!-�� Date Issued r_ •� No. ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes _PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitatlon for bisposal 6pstern (Construction Permit Application for a Permit t e its ct( )Prk'e A Upgrade( ) Abandon( ) [:]Complete System J2 Individual Components Location Address or Lot No. L93(\b(A-Pj �r<,h•—Q Owner's Name,Address,and Tel.No. Assessor's Map/Parcel r 4 q tbclts Installer's Name,Address,and Tel.No. Designe ' Name,Add ess,and el.No. wvw-- t. z Type of Building: Dwelling No.of Bedrooms oL Lot Size f`�,tj�C. sq.ft. Garbage Grinder( ) Other Type of Building y p S� n1�lt�� No.of Persons Showers( ) Cafeteria;,( ) Other Fixtures ,,� Design Flow(min.required) E�_ gpd Design flow provided gpd w. Plan Date i-3Q-10 Number of sheets I Revision Date Title ` 1 Size of Septic Tank P`�15�'1Nt l txin gc,.jf A Type of S.A.S. a.5.,o d,Gll� r�r_.m� 6e Ft W 6 5410 v Description of Soil Nature of Repairs or Alteraiions(Answer when applicable)!t4SV(A rA oe4_�) »(► s� GtI�C� y^ S-rio Q e oA c {ni&_Sq q Date last inspected:, Agreement: t . 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. igned G Application Approved by G Date Application Disapproved by / �/ Date a� / for the following reasons Permit No. - Date Issued ---------------- -- - - - - - --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(41-}0' Upgraded( ) Abandoned( A \ at �j'�"fin/ � G�( has been cons cted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N Il—O ated 2 � Installer S A Designer rt d > 4 #bedrooms `� , (I et�f ;r4 f;r" Approved design flow 2 2 gpd The issuance of his p/e/im(it shall not be construed as a guarantee that the system will ffu •do as designed. Date 3/15- Inspector 1 p , No. ��V Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS x Misposal *p9t Construction Permit t 4 Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) p i System located at t 5 Aq l h /0 Adaf6 �v/ s V !f he Mfg ` 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. d; Provided:Co truc o st `e c mpleted within three years of the date of this permit. ✓ "/�`Ij Date 0 ' Y P Approved by Town of Barnstable �"E r, Regulatory Services Richard V. Scali,Interim Director • BART'BTABM Public Health Division lForAA+a Thomas McKean,Director 200 Main Street, Hyannis;MA 02601 Office: 503-862-4644 Fax: 503-790-6304 ( Installer& Designer Certification Form Date: 3(�5(Zo�b Sewage Permit# 4�ZO1G—a'50 Assessor'sMapTarcel 14113� Designer: bov1 A 1) , 6 v k�D�►` Installer: Zb F? A (A 1. Address: I SS GPd (YydQr Rd S�Oil Address: C�4f eta m, l� O Z0 3 �r �—cd��^c,1�3 O�Z-6317--. On 6;� n T(\K— vas issued a permit to install a (date) G (installer) septic system at a 3 �J0 rtti PILOCINA kA based on a design drawn by (address)dated 1 o� 13d 12016 (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. certify that the septic system referenced above Was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. 1 certify that the system referenced above was coristni tedi"S -coarip ioq with the terms ofthe 11A approval letters(if applicable) ;?' DAVID „ D. " ' COUGHANOWR n _ No. 1 093 nstaller`s Signature) _ { •Sq Ni fin ilk�'� lowk �4j. (Designer's Signature) (Affix Designer's Stamp Here) 1'1,EA:SE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BF. ISSUED UNTIL BOTH T141S FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. IIHANK YOU. Q\SeptieWesigner Ceriiticaliun germ Rev R-14-13.doc. T Bk 29474 Pg102 #9145 02-26-2016 Q 11:31a; DEED RESTRICTION WHEREAS,Emilios Rigas and Anastasia Riggs of 208 Elliott Road, Centerville, MA M632,are the owners of 83 North Precinct Road located in Centerville, MA, and being shown as Lot 16 on a plan entitled"Subdivision Plan of Land in Barnstable,Mass. (Barnstable County)Owned by:Peter G. Sheaffer December 8, 1973,Scale 1"-40' by Cape Cod Survey Consultants,A division of Boston Survey Consultants, Iyanough Road(Rte. 132),Hyannis,Massachusetts,"which plan is duly recorded in the Barnstable County Registry of Deeds in Plan Book 281,Pages 73 and 74. WHEREAS,Emilios Rips and Anastasia Rigas, as the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre- condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.00 State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; W MAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance With 310 CMR 15.200,State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property,is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW,THEREFORE,Emilios Rigas and Anastasia Rigas do hereby place the following restriction on the above-referenced land in accordance with their agreement with.the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 83 North Precinct Road,Centerville,MA may have constructed upon the lot a house containing no more than two(2)bedrooms. Emilios Rigas and Anastasia Rigas agree that this shaU be a permanent deed restriction affecting the house located on 83 North Precinct Road, Centerville,MA,and being shown as Lot 16 on the plan recorded in Plan Book 281,Pages 73 and 74. For title of Emilios Rigas and Aanastasia Rigas, see Deed recorded with the Barnstable Registry of Deeds in Book 28285, Page 287. Property Address: 83 North Precinct Road, Centerville, MA 02632 Executed as a sealed instrument this a•25 day of February, 2016. YJ Emilios Rigas Anastasia Rigas COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. On this Zqb day of February, 2016, before me, the undersigned notary public, personally appeared Emilios Rigas and Anastasia Rigas, and proved to me through satisfactory evidence of identification, which was a MA driver's licenses, to be the persons whose names are signed on the preceding or attached document, and acknowledged to me that they signed it voluntarily for its tated purpose. U<l�j Vic. Notary Public: ba(b$a %-z end eqMy commission expire -7 I 15/ao) i TOWN OF BARNSTABLE LOCATION S3 Ncl,s'o� ) Cnj SEWAGE# 2013 - G VILLAGE 1 IS ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. B i Z CXCayo'J i O-3 y`)7-OGS3 SEPTIC TANK CAPACITY /000 !?0J LEACHING FACILITY.(type) kI;oT, =A V I O)(size) J/ x ZS' NO.OF BEDROOMS OWNER Sa- A L 5 n o PERMIT DATE: S•2 I - 13 COMPLIANCE DATE: 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on`< site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY AZ- sz. j43- ` FRCOT N133- � l � �o� p Ay- 92 Qy (06',�slip O O 3 _ r LOCATION � � so � � SEWAGE PERIAIT NO. VILLAGE CY5 �yr INS TA LL R'S NAME &ADDRESS TrG Ca % g j BUILDER OR OWNER CCU 06 � � T DATE ,PERMIT ISSUED DATE COMPLIANCE ISSUED /�� i ;,� '� 3s � ,� � � �� 1 "� �� SOL TEST LOG P RC# 149954MBER 31, 2013 DESIIGH CALCULATIGN � SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 2 BEDROOMS X 110 GPD 220 GPD WITNESSED BY: DAVID STANTON. HEALTH DEPT. SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS TEST PIT 1 NORC ATOUDNDWATIn - ZE M N/NOCHNTERESOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN IN C ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT, INSTALL INCHES HORIZON TEXTURE (MUNSELL) MOTTLES NEW 1500 GALLON SEPTIC TANK. 45.10 0-10 Ap LOAMY SAND 10 YR 2/1 NONE FRIABLE DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 42.60 10-30 Bw LOAMY SAND 10 YR 4/3 NONE FRIABLE SOIL ABSORBTION SYSTEM: 30-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 34.10 SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES TEST PIT 2 NO GROUNDWATER ENCOUNTERED PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. 2 MIN/INCH IN C SOILS THE 19 ft.x 9:83 ft x 2 ft LEACHING GALLERY ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED CAN LEACH: INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 45.00 0-10 Ap LOAMY SAND 10 YR 2/2 NONE FRIABLE BOTTOM AREA = (19 x 9.83) 186.7 sq. ft. 42.50 10-30 Bw LOAMY SAND 10 YR 4/3 NONE FRIABLE SIDEWALL AREA = (19+19+9.83+9.83)x2=115.3 s . ft. 30-126 C MEDIUM SAND 10 YR 5/4 NONE LOOSE TOTAL AREA = 302.0 sq. ft. 34.50 FLOW CAPACITY = 0.74 x 302 = 223.5 Sol/day INSTALL A 19 ft x 9.83 ft x 2 ft GALLERY AS CONFIGURED ON @Ali= SEP TI Tj�A NK TTHEO 20Fgal/day REQUIRED FOR A TWO yBEDROOM DESIGN Q - MA Ma TANK TO BE PUMPED DRY AT EXAMINED FOR STRUCTURAL INTEGRITYE OF . LLATION AND INSTALL SOIL A B S O R P T I O N NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. SYSTEM CONSTRUCTION DETAIL REPLACE WITH A NEW 1 in 1500 GALLON TANK USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL � TAPER IF CRACKED, ROTTED DRYWELL In- OR OTHERWISE UNIT---,- COMPROMISED. $ 0 CO 2�jv o` NOT In„ - - TO aw Lo SCALE STONE 1 1 0 .\� { 8.5 ft 8.5 ftt "N - 19 ft 8 ft_6 in A �� INLET OUTLET 500 GALLON DRYWELL COVER COVER DIMENSIONS &. DETAIL INSTALL ONE INSPECTION RISER TO WITHIN THREE INCHES OF FINAL GRADE 3 IN DROP USE & INDICATE LOCATION —► Al FLOW LINE H-10 ON AS-BUILT FROM i UN/T BUILDING 10 In 14 TO D-BOX a 33 Qv,ro GAS LIQUID 000o` 'ODO LEVEL BAFFLE o00 8 5 b 102 in /n STONE BASE IF NEW ION BETWEEN INLET & OUTLET INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXT/LE SEPARAT TEES IO LESS THAN LIOU/D DEPTH FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. CROSS SECTION VIEW CROSS SECTION VIEW -- 2 in PEASTONE 2 in PEASTONE D1STR1BUT1O E� OXx A; 0 28 314inTO E24 F �n 314inT 26 EFFECTIVE o ► :o in I-1/2 in GRAVEL DEPTH 1-112 in GRAVEL in 30 in 58 in 30 in ►2 In 178 in c MIN -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. u') FROM S = -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM n1 TANK y TO REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC O o ^ SAS • CODE (310 CMR 15). INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND �$ T UTILITIES BEFORE EXCAVATING FOR SYSTEM. b In STONE BASE -ECO-TECH-ENVIRONMENTAL RECOMMENDS THE INSTALLATION 27 CROSS SECTION VIEW E OF LOW FLOW FIXTURES G APPLIANCES, AND PERIODIC PUMPING OF THE SEPTIC TANK. S -SYSTEM NOT DESIGNED TO WITHSTAND VEHICULAR. LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. F .. TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC EL 47.68 +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 45.45 D-BO r� 3, USE H-20 MAX EXIS 43.15 EXISTING 1000 G, LhOUV o°an o a tl 000a�o PRECAST aga000�ooa SEPTIC TAN K- 43.70 o`pI bo$�op DRYWELL 42.50 °$ 6 in EXISTING REFER TO DETAIL BOX STONE SOL ABSORPTION + 42.67 BASE 42.40 4- EXISTING1 6 In STONE BASE IF NEW SYSTEM —REFER TO 13 ft 4-10 ft DETAIL BOX 40.40 NO GROUNDWATER MOTTLING OBSERVED _ 34.70 SEWAGE DISPOSAL SYSTEM PLAN 83 NORTH PRECINCT RD MARSTONS MILLS, MA JANUARY 30, 2016 ETE-4027 PG 2/2 ' A DEED RESTRICTION NOTES LIMITING THE DWELLING'S BEDROOM CAPACITY TO TWO TREE REMOVAL AT INSTALLERS DISCRETION. 45 SHALL BE RECORDED THE BARNSTABLE COUNTY PUMP AND FILL EXISTING LEACH PIT. REGISTRY OF DEEDS. REMOVE ALL CONTAMINATED SOILS IN AREA i� SHARED BY NEW AND OLD LEACHING. REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. / •� VARIANCE REQUESTED ILII 45 MAY BE GRANTED IMMEDIATELY BY V n �� HEALTH AGENT OR HEALTH INSPECTOR. (/ 310 CMR 15.2111U SOIL ABSORPTION a AREA = 17616 sf+- �� 44 SYSTEM TO CELLAR WALL. 20 ft MIN 1 PLAN BOOK 81 PAGE 73 REQUIRED - VARIANCE TO 10 ft 1 43 SEPARATION REQUESTED. ASSR MAP 18 Pa 134 42 INSTALL 40 MIL POLY LINER"•"""'•'- 4 I /%` 41 36 f pnn ' I t 34 V PROPOSED SOIL ABSORPTION L Q SYSTEM I / -SEE DE AIL 100 fit FROM WETLA D 44 ON 8 CK I � w Z -- I qo I 1 •, i• �,. O�PQNST LE GI S DAT O 0 ft �o 15 in Q ELEVATION a� OAK 43. 69 0 OF WATER 1 (� 1 lO%ft• W �� hIZ N. W 12 inft OAK MINIAL I ®Z ® 5r� W GRADING � � I ® O G2� PROPOSED 0 LdI Q kQ0 / W- C) (�/ d 0, — I SlL T BARRIER (typ/ O ® d ' WATER G• v ® ® / AIL 1 GATE WATER a 1 LINE I / w 0 o / o 1 PA V�D DRIVE WA Y i If \ GARB I / G R OT l OWED 1 44 LEGEND 120.00 ft SEPTIC COMPONENTS 44 43 4241 -- 34 EXISTING I LT BARRR ER 7000 GAL (CONSTRUCTION DETAIL FIL 1� N SEPTIC TANK i DOUBLE �.1 THIS IS A • EXISTING STAKE SCALE: I in 20 ft �0�� LEACH PIT/ HAY STAPLE CESSPOOL BALES FILTER O 20 40 PLAN FABRIC USE COLOR PLAN ONLY TO O 10 20 FOR INSTALLATION DISTRIBUTION BOX STAKE - FULL DETAIL IS BEST TEST PIT ® PRINT ON 8-1/2 x 14 in VIEWED IN " x ;.' PAPER FOR PROPER SCALE FULL COLOR THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM gy p' N DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING fix{ . PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS. OWNER MARS SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. NORTH TH pD MILLSPRE , (INCT - ^ O- -- SEWAGE DISPOSAL MA LOSS Cj p0 z�1 &AAAAAA SYSTEM PLAN �� ECtN 9 ZN OF ss (H OF At4S -TO SERVE EXISTING DWELLING 5 pP O DAVID 9CyG DAVID s'`ti E M I L I O S A N D a D. S o F9l COUGHANOWR v, COUGHANOWR A N A S T A S I A R I G A S NOT No. 1093 No. 461 •` `,J OWNER(S) OF RECORD sc°E 'PFGI o =_=%° 83 . NORTH PRECINCT R RD s so P MARSTONS MILLS, MA TH A U Geo`R der Rd S MO y F AL � PROPERTY ADDRESS ROUTE 28 °k° o AlA Chatham. MA 02633 Dovidcou(9)HotmoiLcom DATE: JANUARY 30, 2016 L O C U S MA P 508 364-08 4 PG.lI2 JOB# ETE-4027