HomeMy WebLinkAbout0072 BUNNY RUN - Health 72 Bunny Run
Barnstable
A = 234 -032 '
Commonwealth of Massachusetts
Title 5 Official Inspection . Form'
it Subsurface Sewage Disposal System Form -Not for,Voluntary:Assessments
72 Bunny Run
Property Address
Robin Pearl
Owner Owner's Name
information is
required for every 0efA4PA4@.. MA 02632 7-25-18
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. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
1 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 , r , ❑ Conditionally Passes ❑ Fails,
❑;Needs Furthe y tion by the Local Approving Authority F
7-25-18
Inspector's Sig ature " ' Date
The system inspector shall submit a copy of this'inspection report'to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection.If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1'of 17
Commonwealth of Massachusetts
r,
Title 5 Official Inspection Form
10111 Subsurface Sewage Disposal System Form, Not for Voluntary Assessments -•d\ �`` Bunn 72 'r_ •T, :� y Run - -
Property Address
Robin Pearl
Owner Owner's Name
information is a
required for every Centerville MA 02632;. 7-25-18•
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: y '
® 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: a
System is in good working order with no sign of failure.
B System Conditional) Passes:
Y Y
❑ 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 ❑N ❑ ND (Explain below): .
t y
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
a 3 Title 5 Official Inspection For
N Subsurface Sewage Disposal.System Form -Not;for Voluntary Assessments ,
72 Bunny Run
Property Address °z
Robin Pearl
Owner Owner's Name
information is
required for every Centerville MA 02632 7-25-18
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 pipes) or'due to'a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health): `
❑ broken pipes) are replaced ❑ Y ❑N ❑ ND (Explain below):
Elobstruction 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,
y 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form`
I� w_•
C"i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r� <
72 Bunny Run
f,
Property Address
Robin Pearl
Owner Owner's Name
requir formation
fo is Centerville MA 02632 7-25-18
required for every
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
or clogged SAS or cesspool
❑ - ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
Bins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts ; ' • @ =
,. Title 5 Official Inspection Form -
xi Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
72 Bunny Run
Property Address
Robin Pearl ,
Owner Owner's Name
information is
required for every Centerville MA 02632 7-25-18. ,
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes . No
❑ ® Required pumping more than 4 times in the last,year NOTdue 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
E], ® 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`wthin 50 feet of a private water supply well.
0 ® ¢Any`portion of a`cesspool or.`privy is,less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
s -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
,4. 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
w µ t s 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`dririking water supply
11 ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
c Commonwealth of Massachusetts ,
,111 Title 5 Official Inspection Form
ri Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,
r�d!
.;> 72 Bunny Run
Property Address
Robin Pearl
Owner Owner's Name
information is required for every Centerville MA 02632 7-25-18
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No -
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ . ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the'site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ ' 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.
® EJ 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 flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
Y,1 Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
,; ` 72 Bunny Run
Property Address
Robin Pearl
Owner Owner's Name
information is required for every Centerville MA 02632 7-25-18
page. City/Town State Zip Code Date of Inspection
D. System Information „ : -
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.) `
Laundry system inspected?4-' F ❑ Yes ® No
Seasonal use? ,, ® Yes ❑ No
Water meter readings, if available•(last 2 years usage (gpd)):.
Detail:
'2 h
Sump pump? , ❑ Yes ® No
Last date of occupancy: 7-2018
t Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): f . - • Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft:, etc.):-
. .
Grease trap present? Rti ❑ Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'� HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y rY
72 Bunny Run
Property Address
Robin Pearl
Owner Owner's Name
information is Centerville MA 02632 7-25-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) i
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner--pumped 2yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool _
❑ Privy -
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under.contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
1a ,'.p Title 5 Official Inspection form
0 Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
;.;. 72 Bunny Run
Property Address
Robin Pearl ,<
Owner Owner's Name _
information is Centerville ' MA 02632 7-25-18
required for every
page. City/Town • State Zip Code Date of Inspection
D. System Information (cont.) .,' _ i #. `
Approximate age of all components, date installed (if known) and source of information:
2000's
f
Were sewage odors detected when arriving at the site? , . :,❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: , ;
24"
feet
Material of construction: r
?' cast iron - "r " ® 40 PVC' ' `❑ other*(explain): i
Distance from p'rivate'water supply well or suction tine:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
1811
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene.° :_. ❑ other(explain)
If tank is metalJist age: years
Is age confirmed by a Certificate of Compliance? (attach a�copy of certificate) • ❑ Yes ❑ No
Dimensions: r 1000 gal
1211 ,
Sludge depth:
t5ins.doc-rev.'6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
jai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 72 Bunny Run.,- ' {
..1
Property Address
Robin Pearl
Owner Owner's Name
information is Centerville MA 02632 7-25-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness a, 0 _
Distance from top of scum to top of outlet tee or baffle
6e
Distance from bottom of scum to bottom of outlet tee or baffle
16"
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.
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
h. hi Subsurface Sewage Disposal System Form.-Not for,Voluntary Assessments
72 Bunny Run
T,y�!
Property Address ,
Robin Pearl
Owner Owner's Name
information is required for every Centerville MA 02632 7-25-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet_and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
'CA I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Bunny Run
Property Address
Robin Pearl
Owner Owner's Name
information is rec uired for every Centerville MA 02632 7-25-18
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 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.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection _Foft
Mi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Bunny Run t r
Property Address n
Robin Pearl _ r
Owner Owner's Name
information is
required for every Centerville MA 02632 7-25-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
'-t y.. r r<'. • - fTt. '=4} .. : 'fir. ' .j r.` ,. r°. � �e t '` ,.
Type:
❑ leaching pits - number:
® leaching chambers number: Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:,
❑ leaching fields rnumber,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.): ,,_
Infiltrator field in good working an order and holding 3"of water and no sign of back-up.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—'top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16,• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
,. Title 5 Official Inspection Form
'I i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
72 Bunny Run
Property Address _
Robin Pearl
Owner Owner's Name
requiratifo is Centerville MA 02632 7-25-18
required for every
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.):
r ,
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
w. Title 5 Official Inspection . Foft:
'�M Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 72 Bunny Run
Property Address , -
Robin Pearl
Owner Owner's Name v ,
information is required for every Centerville �,:,, ' • MA 02632 7-25-18 -
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.doc-rev.6/16 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
c Commonwealth of Massachusetts �. • k . -
,w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "
e 72 Bunny Run
Property Address `• '
Robin Pearl
Owner Owner's Name <
requir atifo is Centerville MA 02632 7-25-18
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: 1 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:
f
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
fia Title 5 Official Inspection Form
wJ
14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. . '
72 Bunny Run
J Property Address
Robin Pearl _
Owner Owner's Name
information is required for every Centerville MA 02632 7-25-18
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Common wveat t of MaaSa ------
TWO(
Snce Sewage ttsystem' - AssessmentMa
s
72 Bunny Run.Rd.
Property Address
Daniel Babineau
Owner OmWs'Name
infonna on Is
FM*ed,for emy Centerville MA 02632 9/23/13
page CRYMO im SWe TP Code . of Ifooeetion
Irk results must be mrbmWed„on form.tnspe6fm-fbfms may not be ':in-any,.
Way.Pleas see completeness checkfist at theerid,of the form:
Imp°'ant MW A. General tnfonnation
fitgr�ouf toms .
on the computer.
use ony the tab. 1. Inspector
key to move your
-do not.
Jason Bumie
ASS
use the reborn Name of Irrspeetorkey-
Neighborhood Waste Water
Company Name -
350 Main St
Cwnpany Address
W.Yarrnouth AAA` 02673
Cityfrown State Zip Code
508-775 2820 S15011 .
Telepfe Nunber License Number
B. Certification
I certify that l have personally inspected,the sewage disposal system:at ttus address arW t#W the
information mportd below is true,murate and..00R, ftn. Theron
Was performed based on.my training and e ce in Vw proper fitnr lion and -
serage dispose systems.l am a DEP; system =c#
-rMe 5(310 MAR 15.ft W Thesystem:
® Passes ❑ ConditianaUy Passes ❑ Fail
❑ Needs Further-Evaluation by the Local Appoft Arity
9123/13
trapeews SWOu Date
The system inspector shall submit:a copy this report to the Approvi Author y
of Hutt or)3EP)wi#lin 30 days of ag this tnspfion.If the system astedsyste ,or
hasa des'O
" cf 102000;gpd or greater,tti i�and ft.systen c t s tlm
report to ttw regrtal ogfce of Ole DEP The original sad 6e serrte sin.aermer
and:oopies serrt to#*buyer;if applicable,artd'the; prcwit `_
*'`**This:repo,#oar.desatbes c ns at tub of bad vndw :of use
ata time.Titus i� does not addr -hoar the i toe# etdec-
t#�abode or clgfet cones af.use.:
lf �
t5it•SM$ Title 5 Ql6dal . s ace sewer o> Syslem.Pape 1 of 7
Commonwealth of MassacMusett�
NIZIMERe
Tie 5 tcct FQt
Subsurtace Sewage Disposal System Form-Not for Uoluraary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
Owner Owner's.Naryblomiation is
required for every Cenb vft i MA 02632 9123113
per. Cityrrown Steae. Zip Code Date of inspection
B. CeMcation (cone.)
n Summary. Check BCD or E/ahva edk .corn late al of Section D
nspecdo A, p ary' . ys
A) System Passes:
1 have not found any information which indicates that any of the failure criteria described
in.310 CMR 15.303 or.in 310 CMR.15 304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
13) System ConditionallyPasses:
❑ One or more system components as;,described in the°Coed ial Pass.. sectip a.cad,to be "
replaced or repaired.The system.upon of..the replacern Id or.repair,as appF+oved.bY
the.Board of Health,will pass.
Check the box for°yes',°no°or°not determined°(Y,N,ND)forthe:Wowing -If'not,
determined,'please explain.
The sepfic:tank is metal and over 20 years old"or the s k(whether metal ornot)is structur#Y
unsound,exhibits substantial infiltratron or exftkrahora or tank to ure cs imtn�ent.Sy n wtii pass
inspection if the existing tank is r with a compIM-septic tank4it� time Board of
Health.
"A metal septic tank will pas inspecfion,if its structurally sound,not Acing and f a;tr ..of.
Complianoe.indicating that the tank is less than 20 years old is-available.
❑ Y ❑ N ❑ ND(Explain below):
t9M•3M3 Me5..OMcW M FOM&bUt a Sewage Dfaposet Sys,•Page 2td 17
Commonwealth of Massachusetts
Tile "Inspection Farr f
Subsurface.Sewage Disposal System Form-Not for jVoluntary A►ssessrnents
72 Bunny Run Rd.
Property Address
Daniel Babineau
Owner Owners Name
WWnequk�' Centery is ille - MA� 02632 M3113
r �every
Cityrrown State Zip Code Date of knpedon
B. Certification (cont.)
❑ Pump Chamber pumpstalarms,not operational System will pass with Board of.Health approval if
pumps/alarms are repaired.
B) System Conditionally.Passes(cunt.):
❑. Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box System will
pass inspection if(with approval of Board of Health):
broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction-is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND(Explain below): ;
❑ The system required pumping more than 4 times a year dire to.broken or obstructed pipe(s).The
system will.pass inspection if(with approval of the Board of Health):
❑. broken P4(s)are replaced ❑ Y [1,N ❑ ND,( )�
❑ obstruction is removed ❑ Y ❑ N ' ❑ ND(ExplairrbeJow)
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#o protect public health,safety:or,the environment,
I. System will pass unless.Board of Health determines in.acco whh.310 CUR_
1&303(1)(b)that the.system Isno#tunctionmg in,a.maser which will-p P
andI me.envviroement:
❑ Cesspool or privy is within 50;feet of a surface water,
❑' Cesspool or pnvy.is within:50 feet of.a bordering ve9p"wetfand ors alt marsh
t5L%•3M3 We 5'Offift kre 9Cft F0-StmarlaceSWMP Oi eLSysEam+.Pap 3 of 17
CoremonweaM of Massachusetts
Tit S. Offic
sec Form
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessawts
72 Bunny Run Rd.
Prey ads
Daniel Babineau
OMM Ohs Name
irrror r is
required
every Centerville MA 02632 9/23113
per. Cityrrow Stake Zip Code Dme.of Irepewon
& Certification'(cont.)
2. System will.fall: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 systern passes if the well water analysis, performed at a DEP certified gyratory,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 bigger9ed..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.aA=inspections:
Yes No
❑ ® Backup of sewage into facility or system,component due to overloaded or
SAS or cesspool,
Di5derge or ponding of of knnt to the surface of the ground or surbmwat s,;
due to an over toaded-or.-. SAS or cesspool.
Static liquid level in the d tribution box abowoutlet irmut,due to an owed
❑ or clogged SAS or cesspool
Liquid depth in>cesspool is less than 6'below irnnert or available volume is less
❑ ® than day flow
ins•sns rue5OFdd Wdped FOM SftgftBseweaa & n•Peaot1a
Commonwealth of Massachusetts
TItIe5..OW4CW:Inspec# TOM .
Subsuftce.Sewage Dispoeai System Form-..Not for.Voluntary tary dents
72 Bunny Run Rd.
Pwperty Address
Daniel Babineau
owner pwner's Name
wdbffn
requir dog'a Y Centerville AAA 02632. Si 23J13 City/Town side Zip Code Dated inspection
B. Ceri ication (coot.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructer 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.
❑ 0 Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet
from a private water:supply well with no stable.water quardy analysis. (This
system passes if the weN r anal ,performed at a IDEP
laboratory,for fecal cordbrm bacteria indicates;absem and,the presence
of ammonia nitrogen and nitrate n1tre n is equal:to or less than 5.Win,
provided that:no other faiiru+e criteria.are triggered:A copy ofithei
and chain of custody.must:be attached to:tbis form.}
The system is a cesspool serving..a facility w th a design flow of 2aQOgpd,-
10,000gpd•
El ® The system.fails.l have determined that one or.more of the above faikme
criteria exist as d in 316CMR 1&3.03,tiier�ore'# syste The
system owner should.contact the Board of Heafttt to determine. t Willie
necessary;to cdffect.the failure.
E) Large Systems: To be considered a system aMe stem must pence a(acidity a
design flow of 10,000 gpdto 15,000 pd.
For large systems,.you must indicate either°yes'or"no _to each of the lb.wm q,in.add .to.the
questions-in:Section D.
Yes No
❑ ❑ the system is within.400 feet of a surface diriWng,water supply
❑ ❑ the system is within 200 feet of a tributary to a:surface d"y suPply
the system is located in a,nitrogen sensitive area(Interim iw Promotion
Area—1WIW or a.mappecl Zon61[of a pubfic water supply l
if you.have answered'"yes°to any,question in.Secfion:E.thesystem is: a s fi threat,
or answered°yes°in Section a above tt a�ge`system'l�as f 'the owner or opt of;at age
system, as rtif�t:threat under Se ion E unite l D sh l t rade the
system in:axordartce with 310,CAAR 1'5:304 system oar shouldappsoprie
. .regional office of'the Demerit.
t5ir�s•3H9 Tifla50®daf6�p.0-FaRt', S S lam;Page•5of17
Commonwealth of iNas achusetts
Tide 5 Official io$ tign Form
Subsuftce Sewage Form-Not for Voluntary Assessments
72 Bunny Run Rd:
Property.Address
Daniel;Babineau
owner Owner's Name
Wftmrequff fo is Centerville MA M632 9/23113
pave, myrrown state Tip Code Date of inspection
C. Checklist
,
Check.I the following have been done.You rimust indicate`yes°or*rW as to each of the following:
Yes No
I
® ❑ Pumping information was provided by the owner,axupant,or Board of Health
®. Were any of the system corponents pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently.or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available.note as NIA)
® ❑ ' Was the facility or dwelling inspected for sgns 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 dohs uncovered,opened,and the.iraerkx of the tank
inspected for the condition.of the baffles or tees,,material of const #iori
dimensions,depth of liquid,depth of sludge and depth.of scum?.
❑ Was the facility owner(and occupants if dlffersxtt from owner),proud with.
information on the proper maintenance of subsurface SOWW drat systedts?
The size and location of the Soli Absorp SY (SAS}on the.site has
been determined'based on m
0 h❑ Existing information.For-exaumpK a plan.at the'Board of Huth:
Determined in the field(if any.of the fakue:crit6ria related to Part-Cis.01 , El
;
approAma#iort of distance is ble)`[3'10 CMR.45:302(5}j
r
D. System Information
Residential F +
Iow Conditions:
Number of grooms(design): 3 Number .bedrns(aetl}: 2
DESIGN f ow,based on 31k:CMR,15.203,(forexamO*'I j.Q. x#afi bedrooms):
OW•3N3 T05 0fc e1 hopedian Fain Subsurface Sege OMPOd Sy*w-Page Sof 17
....._...-
Commonwealth of Massachusetts
Titte. 5 Offcial iion Fob
Subsurface Sewage Msposa!Stem Form--Not for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel.Babineau
owner owner's Name
infoffnafim is
mored for every Centerville MA 02632 , 9/23/13
page. City/Tow State Zip Code Date bf Irepecfion
D. System Information
Description:
4
Number of current residents:
Does residence have a garbage grinder? El Yes 0 No
is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? Yes ❑ No
Seasonal use? ❑-Yes ❑ No
Wier meter readings, if available(last 2 years usage(gpd)): 2012 5.1;000
201345;000
Detail:
Sump pump? ❑ Yes,:®,:.-No
current
Last date of occupancy: tote
Commerciallindustrial Flow Conditions: .
Type of Establishment
Design flow(based on 310 CMR 15.203): Gabro per clay WM .
Basis,of design flow(seats/personstsq.ft.,etc.):
Grease trap present? ❑ Yes ❑: No
Industrial wastOoldingaank.present?- ❑ Yes E: No
Non-sanitary waste d scharg+ed.to the Title 6:system? ❑ Yes.❑ No
Watec.meter readings,if available:
tF=•9HS Title 5 oftW kwpe*-fa-%*ad ae seep pkpwd&$ftm,•Pap
Commonwealth of Massachusetts
TIVe S of cal Inspe ti.on, ,Form
Subsurface Sewage.Dispose!System Form:-Not for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
owner Owners Name
infoffnation is
mq*ed for every Centerville MA 02632 9/23/13
pa 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: Tank was serviced in 2000 per prior report dated
9/11/09
Was system pumped as part of the inspection?. ❑ Yes ❑ No
If yes,volume pumped: gati
gns
How was quantity pumped determined?
Reason for pumping:
Type of Systems
® Septic tank,distribution box,soil,absorption system
❑ Single cesspool .
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attacft previous inspection r records,-f an
❑ InnovativelAitemative.technology.Attach a oopy.ofthe current operabon and
maintenance contract(to be obtained from system.owner)and a o yof west
inspection of the VA system by system operator under
❑ Tight tank.Attach:a copyofthe W approval.
❑ Other(describe):
tw*•3/13 TWO 5 O&W.kopeciOn-Fow SWwj f-S-geDis=W Sys!n•Page 8 d 17
Commonwealth of Massachusetts
' 5 Official Inscom
in for
ittSubsurface Sewage Disposal.System Form-Not for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
Owner owners game
i , ��every Centerville
MA 02632 9/23/13
page. CWTown State Zip Code Date of inspecUon
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
16 years.per prior report dated 9/11/09
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 32"
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private watersupply well or suction line: feet
.
Comments(on condition of joints,venting,evidence of leakage.etc.):
Septic Tank(locate on site plan):
265
Depth below grade: fee
Material of construction:
®concrete ❑metal ❑fiber.glass Poly ylene [].other(explain).
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?.(attach,a copy of cer e) ❑ Yes. ❑ No
Dimensions: 1
Sludge depth:
t6ft•Y13 Title 50fiad kopecW Fame SW--face SWMP Dis Sel sYsiom•pop 9 Of 17
Commonwealth-of.Massachusetts
�'i 5 C�c�a� ��� � Fit
Subsurface Sewage Usposal System Form Not for Voluntary dents
72 Bunny Run Rd.
Property Address
Daniel Babineau
OWW Owners Name
' 'js
Centerville MA 02632 9/23/13
mqtdmd ffor ,
Pam- CAYNOW State Zip Code Date of ktspec dm
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 2'+
Scum thickness TO
W1
Distance from top of scum to top of outlet tee or baffle ,
Distance from bottom of scum to bottom of outlet tee or baffle 2'+
estimated
How were dimensions determined?
Comments(on pumping-re=nmendations,inlet and outlet tee or baffle condition,suctural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
0 concrete ❑metal ❑fiberglass ❑pyre
Dimensions:
Scum thickness '
Distance from top of scum to top of outbt:tee or,baffle
Distance from bottom of scum to bottom of p"tee or bate
Date of last;purnping: Date
tftm•W Tift5Offi"kapecamE=&&Rd—S-WDwpowr :� Pap.10;of17
Commonwealth of MassachusetCrs
Tim 5 O ci-al: ins coon Farm
Subsurface-Sewage Disposal Systiem Form Not for Voluntary Assessments .
72 Bunny Run Rd:
Property Address
Daniel..Babineau
owner owner's Name
' is
�,;��every Centerville MA 02632 9=13
Palms, Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,stnuctwal 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 grader
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene O other-.(explain):
Dimensions:
Capacity: gallons
J
Design Fkonr: gadons per day
Alarm preserrt ❑ Yes. ❑ No
Alarm level: Alarm in wocking,order: ❑:.Yes. ❑ .No
Date of last.purnping: Date
Comments:(condition of alarm and float switches,etc.):
*.Attach copy of current pumping contract#gquir) I6,topy_,at#achd? : ❑ Yes ❑ No
t5eis•3M3
rde s Oft.d kgedw raga Scbufffeca Sewage o :System•:Psge It or n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal system Form-Not for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
owner Owner's Name
WonnMon is
every Centerville MA 02632 923113
per, Cityrrown State Zip Code Date of.Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution.to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc):.
D-box was in good shape and showed no signs of solids carryover.
Pump Chamber(locate on site plan):
Pumps in working order ❑ Yes 0 No'
Alarms in working order. Yes : No!
Comments(note.condition of pump chamber,conditiion.of pumps and appurtenances;et:):
"If pumps or alarms are not in working order,system:is a conditional pass.
Soil Absorption System(SAS).(locate on site per,excavation not required):
If SAS not located,explain why.
tF=-sns Tree a oftlal man Foxm bless m sewer Disposal sgalan-P%0.12 or 17
Commonwealth of.Massachusetts
Tile 5 Officiat.1- S ct n Form
Subsurface Sewage Dis at.System Form-Not-for Volute Assessments
72 Bunny Run Rd.
Pmperty Address
Daniel-Babineau
Oar Owners rtarne
�
every Centerville MA 02632 9/23/13
page• cityrrown slate TEpCode Date.ofinspedion
D. System Information (cont.)
Type:
❑ leaching pits number.
® leaching chambers number. 3-infiltrators
❑ 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,darnp,soil,condition of
vegetation,etc.):
Infiltrators had 3"of liquid in them and showed no signs of hydraulic failure.
Cesspools(cesspool must be pumped."part of inspection)(locate on siteplan):
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-3113 Title 5 ol8dd won Facet SWaff w Sft"e Disposal System page 13 of 17
Gommonweatth of Massachusetts
Official Inspection Corr
Tale 5 O ,
Subsurface Sewage[)tposal System Form Plot for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
owner owners Name
wired for on�y Centerville 9 MA 02632 9/23113
page City/Town Stabs Zip Code Date of Inspection
D. System Information (cone.)
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.):
tFW•3M3 Title 5 OfH d F—&6-faoe Sewage Dis)-dSysW:•Pegs 14 of 17
Commonwealth of Massachusetts
Title 5. Official lns�,, for
Subsurface Sewage Disposal Sys Form-Not for Voluntary Assessments
72 Bunny Run Rd.
Properly Ads
Daniel Babineau
Owner Owners Nameirredqo z
;;red o may, Centerville MA 0= %23f13
per- cdy/Town State Zip Cott.,. Date of.Ire pecbon
D. System Infomnation (cunt.)
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 belm.
® hand-sketch in the area below
drawing attached separately
JA
, p
.
t%%•3/13 Tme 5 Owdlimpection FowSlbaef a Selvage D spood System•.Paw 15 of a
Commonwealth of Massachusetts
Tide 5. Official Insp oon Form
Subsurface Sewage Disposal,System Form-Notfor Voluntary Assessments
72 Bunny Run Rd. T
Property Address
Daniel.Babineau
owner owners Name
information is Centerville MA 02632 V23/13
reed every
page- CWTown state Zip Code Date of hen
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
Check cellar
Shallow wells
fe ett
Estimated depth to high ground water. 2
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.USES.database-explain:
USGS.topo map-and,town GIS
You must describe how you established the high groundwater elevation:
Town.groundwater contour map shows water below elev.35 and topo map shows property at:elev.
60.Also referenced prior report done on 9/11/09.
AM:247 Zone B 2-3 Mi. 1.8-21.6"
Befiore fling this;hopection Report,pfease see Report:Compl sass:C ecklt t on nett page.
Or•sns Tiae 5 oficid.trapeckn Form:Svc SWAW:DWp0WSy8Wn Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Se"ge[)Wpoeal System Form Not for Voluntary Assessments
72 Bunny Run Rd.
Property Address
Daniel Babineau
Owner Owner's Name
required�every Centerville MA 02632 923113
per- cityrrown State Tip 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
tq.3M3 TM9 5.olfimd trspecbon Form Sbofaoe.Sew W Disposal&/Mm-Page 17 d 17
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you.
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st. FI., 367 Main St., Hyannis; MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: ?/ U// Fill in please:
'j°} APPLICANT'S YOUR NAME/S: I n ie S
x BUSINESS YOUR HOME ADDRESS: "gi n�v Pi ��ri�l�c' /t ox ,,
TELEPHONE # Home Telephone Number 5 _)8 - 2L/q- 3 7i 5
nELL V
F� sY '
NAME OF CORPQRATION SS
NAME OF NEW BUSINESS s n i C c T1FPE OF BUSINESS
'IS-THIS A HOME OCCUPATION?�' 1(� "< NO t ''- �(
N r '
UMBER:' � ��,' (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally opera RLI ness in this town.,
j 1. BUILDING COMMISSIONER'S OFKf
This individual has been informany permit requirements that pertain to this type of business.
MUST COMPLY WITH HOME OCCUPATION
horized Sig . RULES AND REGULATIONS. FAILURE TO
1 COMMENTS: GOMPUY MAY RESULT IN FINIES
2. BOARD OF H AaLTH
This individual has beeen i # ryne, of the permit requirements that pertain to this type of business. MUST�,OMPLY WITH ALL
1. Y V��/1 i�{Ja7-f7i�. ARQ0US IVIATl=RIALS Rc'
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
�]
TOWN OF BARNSTABLE Date: IZ5/ 1 5
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: Loc�sje,I LCu,'-)
BUSINESS LOCATION: 7A 13„nnv P,,n /-en Vle .tiles Dot 63 - INVENTORY
MAILING ADDRESS: �� i3un� �2cr► C�.a/���,�//t tires va 6 � TOTAL AMOUNT:
TELEPHONE NUMBER: S o ss 7 y q 37/�—
CONTACT PERSON: .I ,,,,`P�
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: v e
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts(Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
( Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
X ,5 lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform formaldehyde,
,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
TOWN OF BARNSTABLE
TOCATION 7 J u no( / lZV n SEWAGE# 'M7r S to
VY LLAGE_ _ SSESSOR'S MAP&PARCEL
R 616R'SN E&HONE NO. ��-� ®���1�� Lob-(��q
SEPTIC TANK CAPACITY SOO
LEACHING FACILITY.(type)eXt `trwroP-% (size)
NO.OF BEDROOMS 3
OWNER �GQ O
PERMIT DATE: 663dEE DATEn �'j It
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 leachin Feet
FURNISHED BY & � (��
t 1 4 t ♦l♦ L t t t L t 4 t w♦ \ \ \..t \ L L L 4 L L t-T-"r'-r—+- `'
' f / f F ! / f f J / / F F J'f f / f J f J J f F f \ L 4 \ ♦ \r
4 t \ L L`t 4 t 4•\ \' 4 \ L t t \ t 4-L 4.4"\ 4 L t 4 / / f / f : y•�✓"'-'.
L \ L t t t 4 4 \ t \ ♦ \ \ L L \ L \ \ f f F f f f I "
f / f J f f J J J f f f f / / f f f f ! f / ♦ \ \ ♦ ♦ ♦ k
\ \ \ \ \ ♦ \ 4 \ 4 L \ \ t \"\ \ \ \ f J F f F l F '
\/\/\f\/\f♦ft!\f\!\ \/\! \f\F J /\/\f\f♦/\f♦f\ 4 }�1 \�_4__�if
L \ ♦ L L \ \ L ♦ \ \ ♦ 4 \ \ 4 ♦ \ \ -4 \ \ \ 4 \ t t f / f f f I f .Y
-
\ \ \ \ \ '\ ♦ \ \ 4 \ \ t \ 4 1 4 t t \ 4 \ t o t \ t ! f f F F J f
J J f / I ! f I \ L \ \ \ \ ♦
t \ t \ \ \ 4 \ \ J f f f J I f
! f I f J f f f ♦ 4 4 4 4 4 t
' \ 4 4 ♦ 4 L L t 4 f f f f f f f
J f f I I J / f L ♦ \ ♦ ♦ ♦ t
t \ L t \ \ \ \ ♦ f / f f f / f
4 9
m
35 21
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Commonwealthlof Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
rt
w 72 Bunny Run i
Property Address
Laurelie Hodgson ; _
Owner Owner's Name
information is
required for Centerville ! MA 02632 September 11, 2009
every page. Cityrrown `I State Zip Code Date of Inspection
Inspection results r ust be submitted on this form. Inspection forms may not be altered in any
way. j
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Important: A. General Information
When filling out
forms on the `
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection, Services Co.
Company Name I
189 Cammett Rdad
Company Address
Marstons Mills j MA 02648
r Cityrrown i State Zip Code
508-428-1779 j S112855
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. T�g inspection
was performed based on my training and experience in the proper function and, a"i�ntenanc� f on e
sewage disposal syskems. I am a DEP approved system inspector pursuant Section '5)340
Title 5(310' CMR 15L000). The system: ' C t
Ica
® Passes ; ❑ Conditionally Passes ❑ FailsLn
co
❑ Needs Further Evaluation by the Local Approving Authority
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September 11, 2009 _
In' pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEO)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�w the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
i L4
ID�
09-180 Hodgson.doc•08/06 j Title 5 Official Inspection Form:Subsurface Sewage Disposal stem-Page 1 of 15
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Commonwealth;of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
�M
72 Bunny Run
Property Address
Laurelie Hodgson i
Owner Owner's Name
information is required for Centerville MA 02632 September 11, 2009
every page. CityrTown State Zip Code Date of Inspection
i
B. Certificati6p (cont.)
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Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes!:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 115.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank is not in need of pumping at this time, leaching system has 2" of standing water with no signs of
surcharge.
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B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced orepaired. The system, upon completion of the replacement or repair, as approved by
the Board oft Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
i
❑ The septic t$nk is metal and over 20 years old'or the septic tank (whether metal or not) is
structurally ttnsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will ass 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.
NO Explain: !
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❑ 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):
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❑ broken pipe(s) are replaced
❑ obstruction is removed
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 15
j
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Commonwealth;of Massachusetts
I
s Title 5 Official Inspection Form
Subsurface SewagI6 Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address i
Laurelie Hodgson j
Owner Owner's Name
information is required for Centerville MA 02632 September 11, 2009
every page. CitylTown State Zip Code Date of Inspection
i
B. Certificati n (cont.)
I
B) System Conditionally Passes (cont.):
❑ distrlibution box is leveled or replaced
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ND Explain:
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❑ The system �equired pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will Oass inspection if(with approval of the Board of Health):
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❑ brolden pipe(s) are replaced
❑ obstruction is removed
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ND Explain:
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C) Further Evalluation is Required by the Board of Health:
❑ Conditions e�cist which require further evaluation by the Board of Health in order to determine if
the system it 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)i that the system is not functioning in a manner which will protect public health,
safety and tihe 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
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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 4n•vironment:
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❑ The!system has a septic tank and soil absorption system (SAS) and the SAS is within
100 Meet 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
supl�ly.
❑ The;system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 15
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Commonwealth! of Massachusetts
4 Title 5 04icial Inspection Form
Subsurface Sewag Disposal System Form - Not for Voluntary Assessments
1
M 72 Bunny Run
Property Address
Laurelie Hodgson _
Owner Owner's Name
information is required for Centerville p
! MA 02632 September 11, 2009
every page. Cityrrown State Zip Code Date of Inspection
i
I
B. Certificatidn (cont.)
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C) Further Evaluati i ion is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more,1rom a private water supply well".
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Method used to determine distance:
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This system plisses if the well water analysis, performed at a DEP certified laboratory, for coliforrn
bacteria indicated 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 dorm.
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3. Other:
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D) System Failure!Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No j
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❑ ® 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
❑ ® i Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
❑ ® ; Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® ' Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
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Commonwealth! of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewag Disposal System Form - Not for Voluntary Assessments
72 Bunny Run _
Property Address
Laurelie Hodgson
Owner Owner's Name I
information is i
required for Centerville MA 02632 September 11, 2009
every page. City/Town I State Zip Code Date of Inspection
I
B. Certificati n (cont.)
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D) System Failure Criteria Applicable to All Systems (cont.):
I
Yes No
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❑ ® ` Any portion of a cesspool or privy is within a Zone 1 of a public well.
El ® i Any portion of a cesspool or privy is within 50 feet of a private water supply
I 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.]
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❑ ® 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 110,000 gpd to 15,000 gpd.
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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
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❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ j the system is within 200 feet of a tributary to a surface drinking water supply
El Elthe 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"yeq" 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 accord bnce with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
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09-180 Hodgson.doc-08106 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth' of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewag� Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is required for Centerville p
MA 02632 September 11, 2009
every page. Cityrrown ; State Zip Code Date of Inspection
i
C. Checklist
Check if the folldwing have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
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® ❑ j 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?
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® ❑ 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
❑ ® i 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?
® ❑ j Were all system components, excluding the SAS, located on site?
® ❑ i 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?
j
® ❑ ! Was the facility owner(and occupants if different from owner) provided with
j information on the proper maintenance of subsurface sewage disposal systems?
;
The size and location of the Soil Absorption System (SAS)on the site has
I
been determined based on:
® ❑ I 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)]
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09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewag Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is Centerville
required for MA 02632 September 11, 2009
every page. City/Town State Zip Code Date of Inspection
I
D. System Information
i
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2 —
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DESIGN flow baked on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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Number of currentUnknown
residents: —
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system;inspected? ❑ Yes ❑ No
Seasonal use? j ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Currently
Last date of occupancy: Occupied
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
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Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
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Last date of occ(pancy/user Date
Other(describe).-I
-
E
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09-180 Hodgson.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of'15
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i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewagle Disposal System Form - Not for Voluntary Assessments
72 Bunny Run i
Property Address
Laurelie Hodgson I
Owner Owner's Name {
information is Centerville
required for MA 02632 September 11, 2009
every page. Cityrrown `i State Zip Code Date of Inspection
I
D. System Information (cont.)
I
General Information.
I
Pumping Records:
Source of information: Tank pumped in 2000
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume p mped: gallons
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How was quantity pumped determined? —
Reason for pumping: —
Type of System:
® Septic tank, distribution box, soil absorption system
II
ElSingle cesspool
❑ Overflow cesspool
❑ Privy
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El Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
t maintenance contract(to be obtained from system owner)
I
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe).-
Approximate ages of all components, date installed (if known) and source of information:
1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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09-180 Hodgson.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1
M 72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is Centerville MA 02632 September 11, 2009 _
required for P
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer,(locate on site plan):
Depth below grade: 2
feet
i
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.):
Septic Tank(locate on site plan):
• 1'
Depth below grade: feet
Material of construction: '
® concrete ❑ metal ❑ fiberglass El polyethylene ❑ other(explain)
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If tank is metal, list age: years
Is age confirmed!by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
----------------'----------------------------------------------------------------------------------------------------------
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Dimensions: 10.5' long x 5.8'wide- 1500 gal._
2"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
32"
t Trace
Scum thickness
t
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address
i
Laurelie Hodgson
Owner Owner's Name
information is Centerville MA 02632 September 11, 2009
required for p
every page. City/Town State Zip Code Date of Inspection
i
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.):
Tank is not in need of pumping at this time leaching system is functioning properly.
i -
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
Dimensions: —
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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
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Date of last pumping: Date
Comments (on plumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as slated 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):
09.180 Hodgson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Foam
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is Centerville MA 02632 September 1 T, 2009
required for _ p _
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions: —
Capacity:
° gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last purnping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of:current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert r
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.):
No solids or high stains present.
Pump Chamber(locate on site plan):
Pumps in working order: El Yes ❑ No
Alarms in working order": a, ❑ Yes ❑ No
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 15
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is Centerville MA 02632 September 11, 2009
required for p
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: .
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Type:
❑ leaching pits number:
® leaching chambers number:
Three Infiltrators
❑ leaching galleries number: —
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: —
❑ overflow cesspool number: —
❑ idnovative/alternative system
Type/name of technology.-
Comments (note,condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Interior of infiltrators were video inspected and no standing water or evidence of surcharge was
found.
09-180 Hodgson.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is Centerville
required for MA 02632 September 11, 2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids —
Comments (notes condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
09-180 Hodgson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
-Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
„ 72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name =---------- ------- --------------
information is required for Centerville MA _ 02632 September 11, 2009
_
----------------------------
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Bunny Run
Water
Service
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•, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 72 Bunny Run
Property Address
Laurelie Hodgson
Owner Owner's Name
information is
required for P Centerville MA 02632 September 11, 2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 20+
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 topo map and town GIS.
You must describe how you established the high groundwater elevation:
Town groundwater contour ma shows water below el. 35 and to o ma shows roe at el. 60.
9 P P P property _
09-180 Hodgson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
t - \ 4
4 VE0
02 OCT _
2000
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS'
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE
Sccrctary
DAVID B.STRUHS
ARGEO PAUL CELLUCCI Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 72 BUNNY,RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Address of Owner: 72 BUNNY RUN CENTERVILLE,MA 02632
Date of Inspection: 9118100
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMEtiT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
14
Date:9118100
Inspector's Signature:
The System Inspector shall sub it a,copy,of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.I\
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE.
Paoe 1 of 11
revised 9i2198
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the
septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure
is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved
by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
_distribution box is levelled or replaced
nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_obstruction is removed
revised 9/2/98 Pape 2 of 11
' SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18/00
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water ,
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh..
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
e
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nla (approximation not valid).
3) OTHER
n/a
ot
revised 9/2/98 Paoe 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continuedj.
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an 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.
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 1/2 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 n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a 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 privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,vo!atile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 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 II of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
revised 9/2/98 Paae 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner: MRS.ELBON
Date of Inspection: 9118/00
Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that
period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site. .
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X Existing information, For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
3(
revised 9/2/98 Pape 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18100
FLOW CONDITIONS
B-91DENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):3'
Total DESIGN flow: 330 gpd -
Number of current residents: 1
Garbage grinder(yes or no): NO
Laundry(separate system)(yes or no):.NO If yes,separate inspection required
Laundry system inspected(yes or no):.NO ,
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO w
Water meter readings. if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
nla
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nla
System pumped as part of inspection:(yes or no):NO .
If yes,volume pumped n/a gallons
Reason for pumping: n/a k'
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information: ,
1997
Sewage odors detected when arriving at the site:(yes or no): NO
'd SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Paae 6 of 11
revised 9/2/98 a'
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9118/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 30"
Material of construction: cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1500G L 10'6"H 5'6"W 5'8""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
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: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.) 11 .
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
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
Dale of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
n/a f
rts.
revised 9/2198 Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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
Alarm present: NO
Alarm level:NIA Alarm in working order: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a c
DES
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _
(locate on site plan)
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
revised 9/2/98 Paoe 8 of 11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
j SYSTEM INFORMATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (3)FLOW DIFFUSERS
leaching galleries, number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields, number,dimensions: (n/a)n/a
overflow cesspool, number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a ,
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE FLOW DIFFUSERS ARE STRUCTURALLY SOUND AND APPEAR TO BE FUNCTIONING PROPERLY.SOIL PROBE DRY IN LEACH AREA.
CESSPOOLS: _
(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: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
r }
revised 9/2/98 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
�tc l` cj�
o �
Ac
DA
c f iP,
,t
revised 9/2198 Paoe 10 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 BUNNY RUN CENTERVILLE, MA 02632 M234 P32
Name of Owner MRS.ELBON
Date of Inspection: 9/18100
NRCS Report name: n/a ,,�.{
Soil Type: n/a t
Typical depth to groundwater: n/a,
e 'a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records "
Checked local excavators, installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
V `
revised 9/2198 Paoe 11 of 11
TO OF BARNSTABLE
L'KATION - SEWAGE #
VILLAGE ASSESSOR'S MAP & L03y' ly
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNERS G �(1
PERMUDATE: COMPLIANCE DATE: °
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
b � ��
'TtYW T.OIF B.�i1�N TABLE,
LOCA.'aON ��,�:,�_ � SEWA09 ,
VII:L�Gfi _ / ctrin-i i4"�SE3SS3R'S Ar1r4J?
A�STA L tt'3 NAIv�8c P146- dm N0
EI C TANK C'PACT'TY l O
SACM01�//�C1�.lTY (�yp�) �► y� ,2�1��5 (scxe)
`JDU fits:oR(�
�S�p►tatio��9t�Eae«a Batv�eeta k�a:
1Vlazlmum�ldju�t�l:Caaut�dwate�'t'abtei��l�c�mtomofiLa�i,hingP�uiti�y
a Pi3vc;Vtl'ptec S1�IY 1�14t1'iid�eaa�iogttciltry . fy�aUs exist
:a etto se within O(f t of t 6Wiit tot )
Ett i�cyE �/ettant�aad Leac
IW09 Facitity(U y-W Waad exile
wltJatti 3W0 feet of teaaiog Pucl�iry) Fse
gt�Qa.ti�► 0 �
Q (�C
02 O
ED
1
A-3-- 3.5-
�f
TOWN OF BARNST ABLE '
>1
LOCATION 72 9&,,YvYWize 5T, SEWAGE #
VILt:AGE GPiy17�?s%�L/(l�l�! ASSESSOR'S MAP &LOT Z341-e3Z
INSTALLER'S NAME&PHONE N0. f ®� i�
SEPTIC TANK CAPACITY /Sow GAL
LEACHING FACILITY: (type)
Le�fi���-3 ,�(size)
NO.OF BEDROOMS 3
BUILDER OR OWNER Q >�°
PERMTTDATE: Z-Z 15�-7 fg COMPLIANCE DATE: 1,
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
RCAF,
d
3b O �+'b'
SO
.341—O3 z
6 NO. �` ` 1 Fee 3 J"
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
!.� Yes
(f PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migpogar *pwm Congtruction i3ermit
Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) Vcomplete System ❑Individual Components
Location Address or Lot No. ,f� — Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ,I•plr�v� ,T®el
Installer's Name,Address,and Tel.No. /v Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(
Other Type of Building regc-e No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Jf® gallons per day. Calculated daily flow 3r� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank W Type of S.A.S. /JAI'ZQXZ
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) y'/�L'X7 /e,W,;�^
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this BjFd Health.
Signed Date Z 00'
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued .;V' �;Z :-5
r No. Fee 4+
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS, Yes
ar application for Digpogal *p$tem Construction Permit
Application for a Permit to Construct ✓ Abandon pp ( )Repair( )Upgrade( ) ( ) LJ'Complete System ❑Individual Components
Location Address or Lot No. 7 eli oi3
Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel �+� �'v ✓®e��� �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(
Other Type of Building.g�11Ce No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /40 gallons per day. Calculated daily-flow gallons.
Plan Date Number of shetits Revision Date
Title
Size of Septic Tank Type of S.A.S. ✓1.►'L�XZ
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
�k
Date last inspected:; <,
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' B d f Health. ""
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
i,
Permit No.
Date Issued V
----------------------------------------
THE.COMMONWEALTH OF MASSACHUSETTS !i �✓y`�3
BARNSTABLE, MASSACHUSETTS
(tertificate of (Compliance
THIS IS TO CE TIFY,that//the On-
.,site Sewage Disposal System Constructed( ) Repaired( )Upgraded(l/<
Abandoned( )by O� �G� /
at 1eG/ !1 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No r"'' dated
Installer Designer
The issuance of this permit shall nq, a construed as a guarantee that the system will functi�n_as designed.
Date �, �'a l'�/ti;l ' Inspector
—————————————————————————————----
No. ----- —
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
f Di5po5al *pztem Construction Permit
Permission is hereby granted t Construct( )Repair( )Upgrade(V)Abandon( )
System located at 7Z Okllef $
6e&z���'i/�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this -et_nit.
Date: ,7 Approved b,
�y to/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT`
ENGINEERED.PLANS)
2-1
7.
��- i�/, hereby certify that the:application for disposal works
construction permit signed by me dated 2�Z concerning the
c P g
property located at meets all of the
following criteria:
✓ here are no wetlands located within 100 feet of the proposed leaching facility
ere are no private wells within 1�0 feet of proposed septic system
�4
ere is no increase in flow and/or change in use proposed
re are no variances requested or needed. =
If the proposed leaching faciiity wiil be located within =50 fees of any wetlands.the bottom of:h.e
proposed leaching facility will am be iocateo 'ess:han :ourteen (i-tl feet above the maximum adiusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division'G.I.S. map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
I Z
SIGNED , DATE:
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LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 3,
•
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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