HomeMy WebLinkAbout0071 ANSEL HOWLAND ROAD - Health 71 ANSEL HOWLAND RD., CENTERVI I+E
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-BASTING$.Yfl_
Barnstable
Town of Barnstable
IME Tp�
Regulatory Services Department N,AmaloactY
i `"R `LNSTAB
i Public Health Division
F0 + 2007
200 Main Street, Hyannis MA 02601
i e - 2-4 44 •r Office: 508 86 6 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2508 7770
April 15, 2013
Ms. Ann Drake
71 Ansel Howland Road
Centerville, MA 02632
• The septic system located at 71 Ansel Howland Road, Centerville,MA was last
inspected on 4/17/2013 by James D Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
.under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The distribution-box needs to be replaced.
You are ordered to repair or replace the septic system,within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result.in future
enforcement action. _
P=McKean, S.
F HEALTH
• Agent of the Board of Health
Q:\SEPTIC\conditionally passed\71 Ansel Howland Rd.Cent May 2013.doc
T
Commonwealth of Massachusetts
t Title 5 Official Inspection, Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
` 71 Ansel Howland Rd.
Property Address
Ahn,Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Cityrrown state Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling form
out for uunlanu�r
on the computer, ^ OF M,gss!Oij��
use only the tab 1. Inspector. ���. ' ��'
�t .s
key to move your gam: JAMES G
cursor-do not. James D.Sears =z: m,
use the return Name of Inspector =GQT', S€A��—r v,
key.
CapewideEnterprises,LLC
��•.
Company Name �i�'-'�T:.-•G�``�.
153 Commercial Street , 'NSptE`„o
Company Address
Mashpee. MA 02649
City/Town State Zip Code
508-477=8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
. � 4-18-13
e�ftpectoes Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and Copies sent to the buyer, if applicable, and the approving authority.
'This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
� 0
t5ins•3/13 Tine 5 Official Inspection ibsurfaoeSewage disposal System•Paga of
Apr 19 13 10:00a p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is Centerville
required for every MA 02632 4-17-13
page. Cilyfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass' section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y,-N, ND) for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank (whether metal or not)is structurally .
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank'is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
.Apr 19 13 10:01a p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is
required for every Centerville MA 02632 4-17-13
page. CRylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Need to replace D Box
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5irs-3113 Title 5 OfridA InspeCioo Form:Subsurface Sewage Disposal System•Page 3 of 17
Apr 1913 10:01 a p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
71 Ansel Howland Rd-
Property Address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
page. City/Town State Zip Code Date of Inspection
B. Certification (tong)
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 margog is less than 6n below invert or available volume is less
than %day flow P17^
ISlns 3l13 Title 5 Official Inspection Form:Subsurfeoe Sewage Disposal System-Page 4 of 17
Apr 19 13 1 0:01 a p.5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15;000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113 Title 5 Official Inspection Form:SubsuRaoe Sewage Disposal System•Page 5 of 17
Apr 19 1310:02a p.6
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is
required
for for every Centerville MA 02632 4-17-13
page, CitylTown 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? (ff they were not
available note as NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)1
D. System Information
Residential Flow Conditions: -
Number of bedrooms(design): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 for example: 110 330
. ( p gpd x#of bedrooms):
t5ins-3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 o117
Apr 19 13 10:02a p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The System is a 1000 Gal. tank D Box and pit.
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2011-19,00OGals
g ( y g (9P )�' 2012-54,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercialllndustrial Flow Conditions:
Type of Establishment: - -
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No.
Water meter readings, if available:
Sirs.3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Apr 19 13 10:02a p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Cityrrown State Zip Code Date of Enspedion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 04/O8
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of'17
Apr 19 13.10:03a p.9
Commonwealth of Massachusetts
. UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
1983 Permit#83-520
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
'
Depth below grade: 34„feet —
Material of construction:
❑ cast iron ❑40 PVC ®other(explain).-
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing to and from D Box 4" PVC SCH 20
Septic Tank(locate on site plan):
Depth below grade: 26
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast
Sludge depth:
2"
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Apr 1913 10:03a p.10
Commonwealth of Massachusetts
-Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
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
28"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank and outlet cover at 26" below grade whrilet cover at 1',ln and outlet tee's. No sign of leakage
or over loading.
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•W3 Ttle 5 OY'rolal Inspecion Form:Subsurface Sewage Disposal System•Page 10 at 17
Apr 19 13 10:03a p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name --
information is Centerville I MA 02632 4-17-13 required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
c5lns.3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Apr 19 13 10:04a p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Ansel Howland Rd.
Property address
Ann Dake
Owner Owner's Name
information is required for every Centerville MA 02632 4-17-13
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
p q ert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D box is 1Tx16"-35"below grade w/one line out. Wall's are gone, need to replaced box. Note:
Pipeing in and out of box is 4" PVC SCH 20.
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:
15ins-3113 7Ye 5 Olhaal Inspection Fora[Subsurface Sewage Disposal System•Page 12 01:
Apr 19 13 10:04a p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
of Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner owner's Name
information is required for every Centerville MA 02632 4-17-13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number.
❑ leaching chambers number.-
leaching galleries number: -
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.)-.
Leaching is one 1000 Gal. precast pit. Pit and cover at 34" below grade,4"water in pit w/stain line
at 1 B". No sign of over loading or solid carry over.
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 31t3 Title 5 Official Inspection Form SLbsurfaca Sewage Disposal System•Page 13 of 17
Apr 19 13 10:04a p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ll� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.. 71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is Centerville
r MA 02632 4-17-13
required for every
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids —
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System.Page 14 or 17
Apr 1913 10:05a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form
_
Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name
information is
required for every Centerville MA 02632 4-17-13
page. Cltyrrown 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
E,4 R
O 3
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 15 or 17
Apr 1913 10:05a p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner Owner's Name -- --- --- _ --
required for every information is Centerville MA 02632 4-17-13
require
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Ado
Estimated depth to high ground water. 46'
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 well SDW 252 at 46'ADJ 3
You must describe how you established the high ground water elevation:
USGS well SDW 252
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Apr 19 13 10:05a p.17
Commonwealth of Massachusetts
1p" Title 5 Official Inspection Form
,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Ansel Howland Rd.
Property Address
Ann Dake
Owner owners Name
information is
required for every Centerville MA 02632 4-17-13
page. CitylTown 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•W13 Title 5 Official InspvAon Form;Subsurface Sewage Disposal System•Page 17 0117
No. U I r Fee Z✓—
THE COMMONWEALTH OF MASSACHUSETTS Entered incom uter:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYiration for -Misposal *pstem Construrtion 3dermit
Application for a Permit to Construct( ) Repair l/) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.'�/ -A e( Owner's Name,Address,and Tel.No. S"d F y.V.- 7//
Assessor'sMap/Parcel a2 A v%,- D a)<42-
VA-5.e.1 a"/IC"d ", G -�
Installer's Name,Address, nd el.No �, 77—W 7 Designer's Name,Address,and Tel.No.
as v-wa-,
Type of Building: rA
Dwelling No.of Bedrooms Lot Size 0 9erlt. Garbage Grinder( )
Other Type of Building I No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
b -Sc�c, AkJb M urn.
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 P
lace the system in operation until a Certificate of
P Y
Compliance has been issued by this Board of Health. l
Signed L Date �Va2� 0I3
Application Approved by zyDate (.) —1 Z
Application Disapproved by Date
for the following reasons
Permit No. 0 /3 Date Issued
4 ' No. V Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in uteri
r Yet'
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Misposal 6pstem Construction Permit}
Application for a Permit to Construct( ) Repair(�/� Upgrade( ) Abandon( ) ❑Complete System M Individual Components 7
Location Address or Lot No.7/ Ai5.411401, Owner's Name,Address,and Tel.No. Sag q ..i/7/
Assessor's Map/Parcel I A%A w , L'►�, ,
Installer's Name,Address nd el.No. 5V?-4 T7—887 7 Designer's Name,Address,and Tel.No.
Ce.P F,�yi'�R-
Type of Building: i n' l
Dwelling No.of Bedrooms �J /{' Lot Size t `�' sgrft. Garbage Grinder( )
Other Type of Building BSI No.of Persons Showers( ) Cafeteria( )
Other Fixtures
f Design Flow(min.required) gpd Design flow provided gpd
4
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
12 EDl.&C�___1)—N K Ali b b 1 QC
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 4N.1 - Xo
Application Approved by ) Date li
r --7 —�
Application Disapproved by Date
for the following reasons
Permit No. 2 Cj I _ / Date Issued t. a /
THE COMMONWEALTH OF MASSACHUSETTS
n
BARNSTABLE,MASSACHUSETTS
�P �Lk Aq
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Vf Upgraded( )
f �
Abandoned( )by a p Q- t,I AQ- 6!! 1 5�3
at 7I AYl ucx�' " f�dL (�L W-7M'41. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 i — 3 dated U
Installer C1,��&le_ Eyyihy t s Designer
#bedrooms IL`�� Approved design flow gpd
j The issuance of this permit shall not be construed as a guarantee that the system will fun icn o t asid"esigned.
Date I 1 Inspector V
i
No. 2-0 13 (' Fee
i THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal &pstem Construction permit
Cf Permission is hereby granted to Construct i ( ) ` Repair(V) Upgrade( ) Abandon( )t System located at &sa IA6w _,—vat
j
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mu t be completed within three years of the date of this permi
Date t / r Approved by `-
�EC£"IE0
J U L 2 4 2000
TOW►y0FgLj�jAANgfA 1'
COMMONWEALTH OF MASACHUSETTS '_P &r&�
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION S it I I,
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Address of Owner: 71 ANSEL HOWLAND RD CENTERVILLE,MA 02632
Date of Inspection: 7113/00
Name of Inspector: JOHN GRACI
I 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.02636
Telephone Number: 608-664-6813 FAX 608-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of 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 Evalu io By the Local Approving Authority
Fails
Inspector's Signature: Date:7/14/00
The System Inspector shall su 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.My
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 INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE..
revised 912/98 Page 1 of 11
i�`I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 ANSEL,HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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 of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa 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.
J DLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a brokin,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
M& 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
e_.
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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,
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
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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 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,volatile 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 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner: JOHN BORINI
Date of Inspection: 7113100
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.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:0
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: 1/1/00
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
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):YES
If yes,volume pumped 1000 gallons
Reason for pumping:SYSTEM WAS PUMPED ON 7/3/00
TYPE OF SYSTEM
X Septic tankidistribution 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:
1983 PERMIT 83-620
Sewage odors detected when arriving at the site:(yes or no). NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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: 4"
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_ metals_ 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: 1000G L 8'6"H 5'7"W 4'10
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: 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
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.THE
TANK WAS EMPTY
GREASE TRAP: _
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(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
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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:N/A 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
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
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.)
nla
revised 9/2/98 Page 8 of 111
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,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 LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF
FAILURE.THE PIT WAS EMPTY AT THE TIME OF INSPECTION.RECOMMEND RAISING COVER.
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
tile.
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 ANSEL HOWLAND RD CENTERVILLE, MA 02632 M172 P221 L16
Name of Owner JOHN BORINI
Date of Inspection: 7/13/00
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)
Lj
d A
e
G
Ac ` j
FA 1)
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Address: 71 ANSEL'HOWLAND RD CENTERVILLE Property Addre , MA 02632 M172 P221 L16
P Y
Name of Owner JOHN BORINI
Date of Inspection: 7113100
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/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.)
ii
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
41
�t
revised 9/2/98 Page 11 of 11
'No.. 3' �® Fss....... .......
THE COMMONWEALTH OF MASSACHUSETTS
op-- BOARD OF HE T
............OF...................................................... ............_-----__--..__._-
Appliration for Dispoiittl Workii Tonitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a
.. ...
Address r Lot No.
......................—._............ .... -- ..................................... ..... ..-- - --. ........ ... .... ................
WWI Address-
... .... ......••-•--- ...._._....................
Installer Address /
d e
Type of Building Size Lot.... .
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbag_ _�Grin r
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteri
dOther ------------- -
W Design Flow.................__.__._ ...._ _.gallons per person per day. Total daily flow.....
WSeptic Tank—Liquid capacit}� .gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. _ ...... Width.................... Total Length.................... Total leaching area....................sq. ft.
xSeepage Pit No._�. -- Diameter.................... Depth below inlet________..._........ Total leaching area_....____._.___...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R: •--•-------------------------•-•--------......................................_----------=--•-------...................................
-----•.............
ODescription of Soil........................................................................................................................................................................
V ----------------------------------------------------------------------------------------------•--------•-•-----------------.._...-------....------•------------------.._._.......---•-------------------
W ---------------------- --------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------•---
VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
.................................-......................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'l U 5 of the State Sanitary Code—The undersigno further agrees not to place t' a sy em in
operation until a Certificate of Compliance has been ' y the f healt /Z
gned_
D
.. .
ApplicationApproved By------- ..... -1�'.�-- ._...................................._....__.._.._..-------------- ---�-1--....................
Date
Application Disapproved for th following reasons________________________________________________________________________________________________________________
--------------•-----•----•----------_.._......_......_.._._...._............-----•---•---•-•---•-•--....................._---------_--_--
Date
PermitNo......................................................... Issued_.......................................................
Date
"No....................... FEim .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE<H7
.................... .............................. ............ ...............................
for Uhipoiial Workii Tomitrurtion Frrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at*
......................�' io,t............... ... ...... ...... ... .............. ......... ......... ...................... ----------------------- ...........................
ocat n-Address "e6r Lot No
............. ...........................
............................I........... ...................... ...............
------------".......................
nV Address
O—e _ Iw .......................................... .......................
Installer Address
Type of Building 1W Size Lot_...Z 7s 1/',,f
..... .......... q et
Dwelling—No. of Bedrooms.--.... `*`�................................Expansion Attic Garbag(Grid
Other—Type of Building ............................ No. of persons........................---. Showers ete
04 Other fixtures,.............................................................................................. I � 10-V
..........f ----- ----I......
Design Flow............... . . . ..........V1..gallons per person per day. Total daily flow..........`...........A...._...............gallons.
W .............I; ,�S�
1:4 Septic Tank—Liquid capacity,".-e........gallons Length................ Width................ Diameter................ Depth.....--.........
Disposal Trench—No. ................. Width.................... Total Length..................._ Total leaching area....................sq. ft.
> Seepage Pit No.-I.0----- -- Diameter.................... Depth below inlet.................... Total leaching,area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
0-4 Percolation Test Results Performed by.......................................................................... Date........................................
1-4
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water........................
.............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
x
U .....................................I..................................................................................................................................................................
W
x ...................................................---------7.........................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of T I T IZ4 5 of the State Sanitary Code—The undersigned further agrees not to place ti e system in
operation until a Certificate of "XV Com h pli nce h been is' suedeby the boa:fd.6f health.
n ,,.,
S, d
............. At....._............................... .............
ApplicationApproved y................................................................................................. .............
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(9rdifiratr a Tontpliana
p
Y.
S 0 CERTIFY at Indio' ual wage Disposal System constructed�(, or Repaired
by. .. ......./w/.. . . ......... ........ ...............................................................................................................
MG
Installer
at............................................................................................................................................................ --------- --_-------------------------
has been installed in accordance with the provisionsg"I' _LT State San' C &—described in the
)E/ 31 ��X
_,5 of The Sta #a
application for Disposal Works Construction Permit No......................................... ate .... ..........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI LV FUNCTION SATISFACTORY.
DATE.....7AYT.3.................................................... Inspector..... ...
...
)r --------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... ...........................................OF..................................................................................... !OEE........................
.Ieol
PervKsllwals,lyre granted. ....... ... ............ ....... ..................................................................................................
to st tic
AW r OW an e Disposal System
uc (
-
a0........................................................................................................ ........................................ ............................................
Street
as shown on the/al5plication for Disposal Works Construction Permit No....,'..... ...,zeated..........................................
................................ -.... ............................................................
Board of Health
DATE.... ......................................................
FORM 1255 A. M. SULKIN, INC.. BOSTON
LOCATION SEWAGE PERMIT NO.
Cc� lG �� 013-IZLd
VILLAGE :I 'Dal
JAA
I N S T A LLER'S NAME i ADDRESS
S UILDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED 7 Z` ��
yn
30
5IW6LC FAWL-Y BEOROoM �/
d
►JO GARBAGE �jWNDE2
Dom► y W4 ow z IIOX
5EPTIG TA►.IK = 33oxi5o"/• =�95G.P. S`�
ySti= 1000 GAL.
o15Po5n1- PIS- u5E ►voo COAL. � •�
IS►DCv�A�L A¢.Cls = 1>o S.F .. ,�oT/lv
150 $.F, X 2.5 r 375 G.PD /S, 7Z/
50TTOM AREA=
5p s.F x 1• o 5 p G.P p._
'ToTAI-. DESIGN ' 4.25
TDA 1l-"( FL.olr! = 33o G,PO, k �..�. __ _ \ �I
T I
j PE2GOLATION RATE : I'�IN 2MIN ot~LE55 \ 6.7-
777 N EX/ST/�/�
�ilk 0 ASH OF y _
S s I•
RICHARD f o ALAN k N�
A. W.
BAXTER JANES
Na 240484 9:Ob. 251to
0p
*p SURD
-r E�,-r
Logye 1000all INV.
6�+X INS. Sevr�c. •S�•3 -4 .
Z � (000 INS. Sy� TANK .
S4.s�6 LEAGII
PIT INV. INV.
GP.4VEL W I T 11 �• 7 s.�.9
WASNGD
670k5
1 I MEN 47s
I /Z ,.. CERTIFIEh pLoT PI.-AN
'A/v P
4-r 10 N
' S NO SCALE SCALE �•�so " .. DATic /js/83
c�uN�A-r101� P L A t�l IZGF EQEN C.E
1 CE RTIV- -THAT THE SHOWN
IN,9 SOW GOMPL` !S WITN-THE �,IOELIti► � ���-- /�
AWP S�T�e.GK IZ.6Qv►R.EMENT� OF 'T1�� C`c,�-E�2✓/sic
'TOWN O F. 5ACM 67 K3L•.E AND It::,
LOGp.TED WITNIIJ TN Fl.oaD PLAIN
DATE
' BAxTE2e Wye; INC•
REG I S"T E.Q6•D'I.Au D s U R.v
Tu15 PLo.til 1 !:, Wort' an5ti=p o►a AW o3TE9-VILLa • MASs.
I
T
u ENT 5�2vE 'THE oFFSE 5 Staouo .N 5T2 M `( �
No-r i3E 'vSEDTo �ETE.jZ1^IN� t-oT �INs~5 APPLIC.40I ,QL•Q�1/�. S�i4LL�//`/G.