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Home My WebLink About0043 BUNNY RUN - Health 40,Bunny Run Barnstable A = 234 - 023 No. b 15- Fee r � THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pptiration for Disposal Opstrut Construction Permit Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. y(y �IDuMY un Owner's Name,Address,and Tel.No. i Lfi t�� S Assessor's Map/Parcel 2—bcf.4+.tio kn \B�k Ma 0 , Installer's Name,Address,and Tel.go. jT75-@?,a5 Designer's N me,Address,and Tel.No. Type of Building: CAV 6 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �e �Q( (�� 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) �e fl 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 issues by is oard of He Si Date I Application Approved bye` r� � �^ Date f� Application Disapproved by Date for the following reasons Permit No. ( Date Issued I No. O 1 7 1 Fee V THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: / PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes t ` pplicatlon for -Disposal 6pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. qC) QJUnn un Owner's Name:Address,and Tel.No. Lt MT", h5 � Assessor's Map/Parcel Installer's Name,Addres ,and Tel. o. 77j a i Ddsigher's tAe,Address;-and_Tel.No. C-0�- Type of Building: [h�•5 (�ttii(_: - s Dwelling No.of Bedrooms r� Lot Size sq.ft. Garbage Grinder( ) Other ' Type of Building (�,eet� (\� 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 E ,. Type of.S.��.S. Description of Soil "-- l Nature of Repairs or Alterations(Answer when applicable) Date last inspected: r Agreement: ti The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in p j 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 is oard of f . �F ' S' ^f�, �•+►�� Date Application Approved t� € Date Application Disapproved by Date for the following reasons Permit No. C)_a` _ / Date Issued ((/ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS y CJ Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by �� /Gf�/J`i!l r 4I�� .�c� . s"�r'�i C_ �'"',�r�s at 4/Oi?lines ii has been constructed in accordance r with the provisions of Title 5 and the for Disposal System Construction Permit No. '�. � dated Ln 3 Installer C G�� ec `C. �. V�C �f' Designer #bedrooms Approved design flow t gpd The issuance of this p rmit shall not be construed as a guarantee that the system will nc 'off as designed. I Date h Inspector fit,... l �A v _ No.aUis ' Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(\o< Upgrade( ) Abandon( ) System located at uo 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 be completed within three years of the date of this permit. Date �- Approved by ✓�� AsBuilt Page 1 of 1 r 6 OC&TIOM -# 5EW — O. _. '-.- 1NV&LLER 5 ►.I&ME ADDRESS Lc BUILDER'S W &MF— & .DDRESS DATE PERWT 155UED -- D D►T•E COMPLI""ICE ISSUED : JA hftp://issgl2/intranet/propdata/Prebuilt.aspx?mappar=234035&seq=1 6/23/2015 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS --- Permit No.G-10 • Sender: Please print your name, address, and ZIP+40 in this boxO Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 SENDER: COMPLETE.THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A Si ure item 4 if Restricted Delivery is desired. X ❑'Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. Received by rinsed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, �h n or on the front if space permits. 1. Article Addressed to: ' D. Is delivery address.different from item.1? ❑Yes � If YES,,eriteradelivery't;a, ess below: ❑No- 9 cN o Linnea Leedharn-06hs 40"Bunny Run 3. Senric� .� Cen#erville, MA 02632 ❑Certrfi al iority Mail Express- 0 Registered'""❑Return Receipt for Merchandise ❑Insured Mail ❑Collect on Delivery I 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number l l i (Pransfer from service labeQ 7 014 s`12 0 0 0001 035 8 4 0 4 6 �, PS Form 3811,July 2013 Domestic Return Receipt o co Ln O Postage $ us Certified Fee O Retum Receipt Fee p (Endorsement Required)IC3 Restricted Delivery Fee (Endorsement Required) ru Total Postage&Fees $ rl _ r Linnea Leedham-Ochs 40 Bunny Run Centerville, MA 02632 Certified Mail Provides: o A mailing receipt r n A unique Identifier for your mailpiece n A record of delivery kept by the Postal Service for two years r Important Reminders: e Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. • For an additional fee,a Return Receipt may be requested to provide proof of: delivery.,To obtairnlli3turn Receipt service,please complete and attach a Return Receipt`(P8 Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. A - o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. j - IMPORTANT:Save this receipt and present it when making an Inquiry.- PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Town of Barnstable Barnstable 26 MAW Regulatory Services Department , caC j Public'Health Division m 200 Main Street, Hyannis MA 02601 r,2007 Office: 508-862-4644 Richard V.3cali,'Director FAX: 508-790-6304 Thomas A:{McKean,CHO ,,CERTIFIED MAIL# 7014 1200 0001"0358.4046, June 18, 2015 w` Linnea Leedham- Ochs ' g 40 Bunny Run Centerville, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 40 Bunny Run,`Centerville, MA was last inspected,on June 8,2015,by Paul Martin, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed,that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5,(310 CMR 15.00) due to the following: A 0 The distribution box needs to be replaced. ,..., s You are ordered to repair or replace the septic system components within one Q)year from the date you receive this notification. Failure to repair/replace the septic system'.within the deadline period will result in future. a enforcement action. t t: PER ORDER OF AE°BOARD.OF HEALTH q. Thomas McKean, R:S:,::CHO Agent of the Board of Health j Q:\SEPTIC\Conditionally Passes Ltr\40 Bunny Run Cent Jun 2015.doc THE rw g z Y{- M1 :Town of Barnstable STAB 9�prfASS. �` Regulato"ry Services Department; Public'Health Division 200 Main:Street, Hyannis.MA 02601 Office: 508-862-4644, Richard Scali,Director FAX: 508-790-6304 " Thomas A.McKean,CHO ' Feb 6 2007 • Rev:_4/28/15 • DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310.CMR 1-5..000) An"X" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA 3 . ❑ Discharge or ponding of effluent,'to the surface of the ground , ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. - 4a . ❑ Backup of sewage into the house due to an overloaded or clogged SAS or-cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box`above outlet invert due to an overloaded or clogged SAS or,cesspoo115 _ ❑Any portion of the-SAS, cesspool,•&privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 510 feet of�aprivate water "supply well with no acceptable water quality analysis.",(This system passes,if the water analysis -indicates the well is free,from pollution). TWO (2)YEAR DEADLINE CRITERIA- `' ❑ Single Cesspool t . r . ❑ Any"conditionally passed systems"-(broken cover, relocation of a pipe, relocation of a driveway due to.,H-10 components, etc),, b ❑ Leaching pit or cesspool 4with,high'llquid level, <12.below pit(per Town Code ` §360-9.1) < . OTHER 2� 0 Repair deadline: A Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc. . I Commonwealth of Massachusetts M/P oZ3 0367 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M i 40 Bunny Run Property Address Linnea Ochs _ Owner Owner's Name information is CentePA44e /1� _ _ Ma 02632 6/8/15 required for every _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection form_ s may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return — - --_ — — key. Name of Inspector _DiBuo_no Sewer and Drain Company Name --- — 8 Johns path _ Company Address � ,. --------- -- --- , �e S Yarmouth MA 02664 City/Town ----------- -- ------- State -- ��'�, -''�' kiP �1,M;--- - 508-364-9587 S113522 Telephone Number License Number B. Certification — I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site . sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ __ 4�/8/15 In pector's Sign_ature ---- — — Date ---- —--The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection:If the system 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. y� t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection , Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 4_0 Bunny Run Property Address Linnea Ochs Owner . Owner's Name ' information is required for every Centerville M.a 02632 6/8/15 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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 contains a 1000 gallon tank as well as a concrete Distribution box. The concrete distribution box is rotted and the pipe to the second pit is running up hill. All tees and baffles are in place. The leaching is made up of two 6x6 Leaching pits. The second pit is dry.and has never seen flow. 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-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 . 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection B.. Certification (cont.) . ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (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): Dbox needs to be replaced and pipe to second pit may need to be lowered in order for second pit to receive flow. ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a-Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems:. You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or `clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. CityrTown 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. !l have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a.nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in 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 I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GIA, 40 Bunny Run - Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate d cate yes or"no".as to each of the following: Yes No ❑ Pumping information was provided by the.owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part.of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up?, ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3-- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is Centerville Ma 02632 6/8/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. The concrete distribution box is rotted and the pipe to the second pit is running up hill. All tees and baffles are in place. The leaching is made up of two 6x6 Leaching pits. The second pit is dry and has never seen flow. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No . I 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: 110 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Bunny Run Property Address Linrlea Ochs Owner Owner's Name information is Centerville Ma 02632 • 6/8/15 required for every page. CityFrown 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): 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -1 UV." 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. Gity/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 39 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 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.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1.5 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon If tank is metal, list age: —__— years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon „ Sludge depth: 3 _ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'nN 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville. Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) SepticTank (cont.) - Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 3 ' Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or"baffle condition, structural integrity, liquid levels.as related to outlet invert, evidence of leakage, etc.): Levels are normal tee's are in place. Grease Trap (locate on site plan): 9 Depth.below grade:' NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness — x Distance from top of scum to top of outlet_tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): .Tees are in place and levels are normal. 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 M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Needs to be replaced 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.): Distribution Box is rotted and decayed and needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): No signs of carryover and no signs of hydraulic failure. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 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.)-. No signs of ponding or hydraulic failure. 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.): I t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is Centerville Ma 02632 6/8/15 required for every 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 , OCL�TION SEEN o. z3q 83 VILLAGE • — —. — Its! TALLER 5 ►.I&ME ADDRESS BUILDER'S 1.1&VAE �- &.DDRESS —T2TF, , _�v= -- DD,?E PERMIT 155UED — D LLTE COMPLI&. acE ISSUED : III ; a 4 . r r r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is Centerville Ma 02632 6/8/15 required for every — page. . City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells •Estimated depth to high ground water: 25+ ft 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: usgs map . You must describe how you established the high ground water elevation: Property sits 25 ft above nearest water venue.According to usgs maps system is approximately 25 + ft above ground water. 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 M 40 Bunny Run Property Address Linnea Ochs Owner Owner's Name information is required for every Centerville Ma 02632 6/8/15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ` ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS RLICIIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROjT�CTI:OROZ W :t TOWN OF BAMJSTA6t_ HEALTH CREPT. ' TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 40 BUNNY RUN CENTERVILLE,MA 02632 0Z3 - 2,01 Owner's Name: THOMPSON � Owner's Address: 8 CAMPELLO RD FRAMINGHAM, MA 01701 Date of Inspection: 10/14/02 Name of Inspector: (please print); JOHN GRACICOP Company Name: SEP i 3C INSPECTIONS I nC ' Mailing Address: BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of;the time of 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 6f Title 5(310 CM 15.000). The systen;: X Passes _ Conditionally , sses _ Needs Furth valuation by the Local Approving Authority Fails, Inspector's Signature: ^� I Date: 10/14/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect on. 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 suiiniit 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERT' TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes condilions at the time of inspection and under the conditions of use at that time. 'this inspection does not address how-.the:iystern will perform in the future under the same or different conditions of use. All x � '> Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) S n. Property Address: 40 BUNNY_RUN;CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 y' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system compone•nts:a's.described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair.., as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)�in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and,-over'20":years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a 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): i _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed. The system will pass inspection if(with approval of the Board of'Health): 1 broken pipe(s)are replaced _obstruction is removed it ND explain: n/a Page 3 of OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,CERTIFICATION(continued) Property Address: 40 BUNNV RUN'CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 f., C. Further Evaluation is Required byihe 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 unlessi`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 111K, _+ 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 surfacewater�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 frorn a private water supply well**. Method used to deterirrrne distance n/a **This system passes if the well,water;analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indticates�that the well is free from pollution from that facility and the presence of ammonia ;:. nitrogen and nitrate nitrogen"is,equal,to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a r 'I>c Yt Nr z � ' T t.(_ Yq! t . Page 4 of I I .p 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE §E,,WAGE DISPOSAL SYSTEM INSPECTION FORM PART A c CERTIFICATION(continued) �1 Property Address: 40 BUNNY RUN CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or ,no"to,each of the following for all-inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 1�, ` X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow X Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NO PUMPING INFORMATION. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool'or pi:ivy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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. IThis system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this"form:1 (Yes/No)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'lfails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: i To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes",or,`,np"to each of the following: (The following criteria apply to large systems,in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply t � v X the system is within 206`feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered. yes',to any question in Section E the system is considered a significant threat,or answered "yes" in Seclion D above the lame 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 r.should contact the appropriate regional office of the Department. i • E. Page 5 of I I ; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i` PART B CHECKLIST Property Address: 40 BUNNY RUN CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks r X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection '? r, X Were as built plans of the system obtained and examined?(If they were not available note as N/A) f X _ Was the facility or dwelling'inspected for signs of sewage backup? X _ Was the site inspected&for'sigris of break out 7 X _ Were all system components, excluding the SAS, located on site X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information,on the proper maintenance i of subsurface sewage disposal systems`? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no ° X _ Existing information.'For example,a plan at the Board of Health. ` X _ 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(3)(b)] �t„ 1 Page-6 of I I lox OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C e SYSTEM INFORMATION Property Address: 40 BUNNY RUN CENTERVILLE,MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 t FLOW'CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 l Nuinb ,'of bedrooms(actual): 2 DESIGN flow based on 310 CMR-45.203,(for,example: 110 gpd x#of bedrooms): 220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes•or no): NO Seasonal use: (yes or no): NO t. r i% ,l Water meter readings, if available'(last 2 years,usage(gpd)): {a ' —1 V0 0 Sump pump(Yes or no): NO 0 a Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL 't'= Type of establishment: n/a Design flow(based on 310 CMR 15.203);m/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present,a(yes or no): NO Non-sanitary waste discharged to the Title 5-system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use:m/a 'v OTHER(describe): n/a GENERAL INFORMATION Pumping Records � Source of information: NO PUMPING INFORMATION Was system pumped as part o'f the inspection(yes or no): NO If yes, volume pumped: n/agallons_-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil'absorption system _Single cesspool _Overflow cesspool _Privy p _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.TAttach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 BY OWNER #� Were sewage odors detected when arriving at the site(yes or no): NO x a , o Page 7 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,ISEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 BUNNY RUN CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 BUILDING SEWER(locate on site plaii) Depth below grade: 18" Materials of construction:_cast iron X40'PVC_other(explain): n/a Distance from private water supply well'or suction line: n/a Comments(on condition of joints, venting;.evidence of leakage,etc.): TOWN WATER , SEPTIC TANK: X(locate on site plan) Depth below grade: 12" 3 .. Material of construction: Xconcrete metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age.confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS',�.;''1•. . Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 3" Distance from top of scum to top of outlet,tee or baffle: 6" Distance from bottom of scum t6 66tfom of outlet tee or baffle: 15" How were dimensions determined: MEASURED 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 AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVER;Y;TW0 YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan),, Depth below grade: n/a Material of construction:_concrete"{;metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet,tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recon n ucnh daons,.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc,): 4. n/a '1 d 4j; ,• E .,t i l c, ,rl 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ? _ PART C SYSTEM INFORMATION(continued) Property Address: 40 BUNNY RUN CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 TIGHT or HOLDING TANK:,(tank must,,,be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day,'i. , `'` r, Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a , Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present-must be opened)(locate on site plan) Depth of liquid level above outlet invert; LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): ,, D-BOX IS STRUCTURALLY SOUND ` PUMP CHAMBER:_(locate on site plan) r, f Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber—condition of pumps and appurtenances,etc.): n/a - f , 3 R Page 9 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 BUNNY RUN CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a t Type 1000 GAL 6'.X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a ; 4innovative/alternative system t . . Type/name of technology: n/a Comments(note condition of sdil,Wgits'of hy&aulic failure; level of ponding,damp soil,condition of vegetation,etc.): LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. DID NOT EXPOSE ONE PIT,SECOND PIT WAS EMPTY AT TIME OF INSPECTION.STAIN LINES INDICATE SECOND PIT HAS NEVER HAD MORE THAN 1' OF LIQUID IN IT. BOTTOM IS AT 11 F CESSPOOLS: (cesspool must,be pumpe,d as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a - , Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):'NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a i, PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a p Comments(note condition of so.il,isigns of,hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 . Pagel 0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEViAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 BUNNY RUN=CENTERVILLE, MA 02632 Owner: THOMPSON Date of Inspection: 10/14/02 SKETCH OF SEWAGE DISPOSAL;SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate.where.public water supply enters the building. 13 aC�C� /1 A►3 A hc:.u'3 A'EJIO r1L 6A 2p`' ;. 66 17 ex; �)3 Page`] 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 BUNNY-RUN CENTERVILLE,MA 02632 Owner: THOMPSON , Date of Inspection: 10/14/02 T SITE EXAM ' _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate check all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database`explain,:n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. " l e r II LOCL.TION SEW O. VILLAGE _ - IWFNLLER 5 1 &ME 6, ADDRESS _ 6 ► BUILDER 5 Q &MF- ADDRESS D�►TE PERMIT ISSUED D ATE COMPLI W-ACE ISSUED : �'��'- No......................... FE$............................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH::;��. OF. ............�...j. L--------........................•-------- Appliration -for R,ipoiial Works Ton,strurtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - :./.��--C.-_ .6 �__ --------------------------- r --------------------------- Locati Address or Lot No. il wner Address W Ins ller_ Address QType of Building ��,,��,��`,'� Size --------Sq. feet U Dwelling—No. of Bedrooms...............�__-_________ .Expansion Attic ( ) Garbage Grinder (� aOther—Type of Building ............................ No. of persons..-_____--_-____--_-.___-_-_ Showers ( ) — Cafeteria ( ) Other fix u ---------------------------- W Design Flow-------------- _______________________ gallons per person per day. Total daily flow-___-- _ ----___-_--.-.._-_..gallons. WSeptic Tank--�-Liquid capacity W9a. llons Length................ Width................ Diameter_- ............ Depth-.-.___-.----- x Disposal Trench—No- ____________________ Width.................... Total Length-------------------- Total leaching area......... --------sq. ft. Seepage Pit No...................•. Diameter-------------------- Depth below,inlet------___ ___..... Total leaching area-------._°._.____.Sq. ft. z Other Distribution box ( ) Dosing tank - aPercolation Test Results Performed by----------- .............................................................. Date_-__-------------------------------- Test Pit No. 1----------------minutes per inch Depth of "rest Pit.................... Depth to ground water...._._-___----------- f,4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground(Water-----------.------------ f = Description of Soil------------ .�-. _._L'Y��' .�.-li-- -�- Z.. = •---•----••------------------- U .................... -•------------------- .----------------------.a---I. ._ W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- VNature 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. �. Signed --- --------- ----------------------------------------------------------------- Date Application Approved By--------- --- - - -- : . .__..�. •-•--- ---- 1 Date Application Disapproved for the following reasons__________________________________ ________________________________________________________________________•__-_ --•-_--•-••--------------------------••----------•---•-------------------•--•-•-•-----•--•••----------------------------------------•------•-------------------•---------------•_-••--•-•---------_----- // Date Permit No......................................................... Issued.. 1-. 7� Date 7(0 No......................... FEs....... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G ......._.oF .......... ................................. Appliratiun -fur M,ipouttl Work.o Tonmrurtion Vrrmit T Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t: � _ .•-= c on- dre or Lot No -- ----- --- ---- _. . ........... �=--------•----- --------................................. roc_:. wner Address a ................. Installer Address UType of Building ✓.f fie Size Lot_/_�7__ --------- feet Dwelling—No. of Bedrooms----------------3___.___________________---Expansion Attic ( ) Garbage Grinder (� aOther—Type of Building ________________ ________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' F. Other fi_ to w Design Flow___ __ ___________________ _gallons per person per day. Total daily flow_.__-�•.��____ .__..___gallons. g ----------- -- g P P P Y Y WSeptic Tank Liquid capacity .. -__gallons Length................ Width-------......... Diameter................ Depth_....--__-.___. x Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter____________________ Depth below inlet__..______.____.___ Total leaching area---------.--------sq. ft. z Other Distribution box ( ) Dosing tank ( ) --e4 - aPercolation Test Results Performed by----------------------------------------------------------- ___ Date---------------------------------------. Test Pit No. 1------_.........minutes per inch Depth of "Pest Pit.................... Depth to ground water...____._-._._._____.... �14 Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water._._.__..__.___.____.__. O �t - �r f. - - Description of Soils J`u- -._- _. ------ ------------------------------------------------ x , c •----------------------�------ �r-- o �� `��-�l w V Nature of Repairs or Alterations—Answer when applicable._._....................................................................................... r. -- Agreement: The unders gned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prow ons of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operati, n until a Certificate of Compliance has been issued by the board of health. Signed -------------------------------------------------------- Date Application Approved BY -- - '--- ------------ ---- ---di(�4�. = ---------------- Date Application Disapproved for the following reasons___________________________________ _____....______................._____________________________________________ --________-•-----•-----••--------•--------------------------•--•--------------•-•------------•------•-----•---•--••-------------------•---•---•--------•--------------------------••---•••-------------- Date PermitNo----------------------------------------- =..... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS; BOARD ;05 HEALTH ... ........OF........... ...... . ............................. 'ITr tifir tr of Tompliaurr T S I TO ER", ' Y, That t`e ndividual Sewage Disposal System constructed ( ) or Re aired ( ) by- U { nstaller at.--•- �` --------- ------ '�------------------------------................. has been installed in accordance with the provisions of -" *c �he State Sanitary Code as described in the application for Disposal Works Construction Permit No. ----•----- ---------------------- dated__.._.-_/ _'___7l�_..___._____ THE ISSUANCE OF THIS CERTIFICATE SHALE, NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - ...............-............ Inspector-- THE COMMONWEALTH OF MASSACHUSETTS 7G BOARD O HEALTH No..!....... ..... FEE---- �i>� uttl , q unn rtion rrmit Permission i hereb granted. . C� --------------•-•- ----- -- - I------------------------------- --- to Constr tt ( U o epair ( an Indivi wage D sal System at No.- . = .. 1 5 . . , � ----- -- -------------- --- --- Street / as shown on the application for Disposal Works Construction P t N _.t- ____ _____ ated.... __'__.� ._.-.7_C.----- ----- ------ -- ----- --- ------• •. 1% f C l Board o Health DATE--r z ------------------------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 'G- 0 7- 48 ,C N 0 �C o N o a of o N C OT z2 I v CERTIFIED PLOT PLAN L O C A T 1 O N- -45 'y S C A L E: /"=-30" ___ D A T E R E F E R E N C E 8E/1(/�7 7- z i 9 5 -SlYaGf/�C/ 4",�, p�A�v �E coGL7E/� AT '7-/-/c!5-- D A T E I HEREBY CE RTI FY THAT THE BUS L D I N G PEG L PND 5kiRvCY0R 5H0WIN ON T H 1 5 PLAN 15 L 0 C A T E D O N THE GROUND AS SHOWN HEREON AND t t iA aF P�9 THAT IT 20�Q — CONFORM TO THE �� 0 . , �_... :` Z O N I N G B Y - L a w s O F l" H E T- O w N O F GORGE WHEN CONSTRUCTED ----- C) LOW, R. e BARNSTABLE SURVEY CONSULTANT-S' INC: .. wE5T YARiv10UrH 1,4A5 .5 ® �UOf