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HomeMy WebLinkAbout0195 ANSEL HOWLAND ROAD - Health 195 Ansel Howland Road Centerville P A = 171 238 t. NO. 152 1/3 ORA °67J� 1 O0/n fA <y 4 COMMONWEALTH OF mASSACHUSETTS EXEC i E OFFICE OF ENVIRONMENTAL AFFAIRS LT DEPARTMENT OF ENVIRONMENTAL PROTECTION e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM /�/ ^ 2� PART A CERTIFICATION Property Address: 195 el Howland Road,Centerville,MA 02632 Owner's Name:Shelly M.Milano Owner's Address: 195 Ansel Howland Road,Centerville,MA 02632 Date of Inspection:"12/15/2006 Name of inspector:Reid C.Ellis Company Name:Ellis Brothers Const.Co. Mailing Address:23 Enterprise Road Yarmouth Port,MA 02675 Telephone Number:508-362-6237 le CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fimcti and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to tion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �✓ c 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,andathe approving F �"4 authority. C` Notes and Comments `= � N - C71 =2 ****This report only describes conditions at the time of inspection and under the conditions use at that time.This inspection does not address how the system will perform in the future under the sa a or diCn erentEo conditions of use. _ rn I. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 Ansel Howland Road,Centerville,MA Owner: Shelly M.Milano Date of Inspection: 12/15/2006 Inspection Summary: Check A,%C D or E/ALWAYS complete all of Section D A. System Passes: VI have not found any information which indicates that any of the failure criteria described in 310 CIvIIt � 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes.: X One or more system components as described in "Conditional P s' by Boarddt be replaced or H� 11 pass. repaired.The system,upon completion of the replacement r repair,as approvedY Answer yes,no or not determined(Y,N,ND)in the fir the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or a septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as proved by the Board of Health. *A metal septic tank will pass inspection if it is structurall sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availabl . ND explain: Observation of sewage backup or break out or hie static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven di button box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are re aced obstruction is remov distribution box is lev led or replaced ND explain: The system required pumping more than 4 times a ear due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are repl d obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYINSPECTION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM PART A CERTIFICATION(continued) Property Address: 195 Ansel Howland Road,Centerville,MA Owner: Shelly NL Milano Date of Inspection: 12/15/2006 �r C. Further Evaluation is Required by the Board of Health: r� Conditions exist which require further evaluation by the oard 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 15303(l)(b)that the system is not functioning in a manner which will pro pablic health,safety and the environment: — Cesspool or privy is within 50 feet of a surface wate — Cesspool or privy is within 50 feet of a bordering ve etated wetland or a salt marsh 2. System will fail unless the Board of Health(and Publi Water Supplier,if any)determines that the system is functioning in a manner that protects the public iealth,safety and environment: septic The system has a s tic tank and soil absorption syst m(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppl The system has a septic tank and SAS and the SAS' within a Zone 1 of a public water supply. - The system has a septic tank and SAS and the SAS' within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS i less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine di lance **This system passes if the well water analysis,perform at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that thewell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is c jual to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must I e attached to this form. 3. Other: 3 Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A CERTIFICATION(continued) Property Address: 195 Ansel Howland,Centerville,MA Owner: Shelly Milano Date of Inspection: 12/15/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ ischarge 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 — � ool id depth in cesspool is less than 6"below invert or available vohnne is less than'h day flow _ squired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o ' es pumped . y portion of the SAS,cesspool or privy is below high ground water elevation. _ portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface r supply. portion of a cesspool or privy is within a Zone 1 of a public well. _ y 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fai6c.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 se e a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the f llowing: (The following criteria apply to large systems in additi n to the criteria above) yes no _ the system is within 400 feet of a surface g water supply — _ the system is within 200 feet of a tributary to i surface drinking water supply the system is located in a nitrogen sensitive (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section the system is considered a significant threat,or answered failed. a owner or operator of any large system considered a "yes"in Section D above the large system has 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. 4 - 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY 4N FORMASSESSMS SUBSURFACE SEWAGE DISPOSAL SYSTEM PART B CHECKLIST Property Address: 195 Ansel Hawland,Centervill,MA Owner:Shelly M.Milano Date of Inspection: 12/15/2006 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes N _ 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 Was the facility owner(and occupants if different from owner)provided with information of th affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ _ 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: Ye no _ 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(3)(b)] 5 5 Page 6 of I 1 OFFICIAL INSPECTION AFORM PNOSAL SYSTEM INS ECTION FORM ASSESSMENTSOR VOLUNTY SUBSURFACE SE PART C SYSTEM INFORMATION Property Address: 195 Ansel Howland Road,Centerville,MA Owner: Shelly M.Milano Date of Inspection: 12/15/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): � Number of bedrooms(actual): -y DESIGN flow based on 310 CMjt 15.203(for example: 110 gpd x#of bedrooms): O Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system((y�or no if yes separate ins ct►on required] .¢. Laundry system inspected(ye or no);'-� f ' Seasonal use:(yes or no);/ � Water meter readings,if avai le(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIAL/INDUSTRIAL /�A Type of establishment: d Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgf,etcI-- industrial Grease trap present(yes or no):_ waste holding tank present(yes Non-sanitary waste discharged to the Titleno)-_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: !/ Was system pumped as art of the inspection(yes or no): If yes,volume pumpe/�Sallons—Xow was quart p �c etermined? ySeptic pumping: ��I.��_ _ / aw V SYSTEM 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) —Tight tank —Attach a copy of the DEP approval Other(describe): Appro ' ate age fall compo nts ed ' kno )and sflurce f ��- Were ors detected hen am g 6 - 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT SYS EM INSPECT ON FORM VOLUNTARY S SUBSURFACE SEWAGE DISPOSAL PART C 4 SYSTEM INFORMATION(continued) Property Address: 195 Ansel Howland Road,Centerville,MA Owner: Shelly M.Milano Date of Inspection: 12/15/2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC_other(expla) : Distance from private water supply well or suction line: / Comments(on condition of joints,vent g,evidence of 1 �etc)iI 1!v SEPTIC TANK: on site plan) Depth below grade. Material of construction:_concrete_metal fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: ;ig y, Sludge depth: " & Distance from top of s udge to bottom of outlet tee or baffle:r— Scum thickness:_e9 _ O Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outipt tee or bafIle: How were dimensions determined: Comments(on pumping recommen tions,inlet and ou t tee or affle rion,structural integrity,liquid levels as rely to outlet• vert,evidence of 1 e,a C!" GREASE TRAP: (locate n site plan) Depth below grade:— Material of construction: concrete metal— erglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baf le: Distance from bottom of scum to bottom of outlet or baffle: Date of last pumping: Comments(on pumping recommendations,inlet an< outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Ansel Howland Road,Centerville,MA Owner:Shelly M.Milano Date of Inspection: 12115t2006 TIGHT or HOLDING TANK: (tank must be pum at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fil erglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no : Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: .-if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: fV Comments(note if box is level and distnbution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out // ,; oew Zee PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditi(n of pumps and appurtenances,etc.): 8 T:4.1-f r__ Lh f!/nnn R Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Ancel Howland Road,Centerville,MA Owner:Shelly M.Milano Date of Inspection: 12/15/2006 SOIL ABSORPTION SYSTEM(SAS) ovate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: �,/ leaching chambers,number. I leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number. Q innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, 4d" elf CESSPOOLS: (cesspool must be pumped as part of ion)(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 or no): Comments(note condition of soil,signs of hydraulic fail ,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 fail ,level of ponding,condition of vegetation,etc.): 9 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Ansel Howland Centerville,MA Owner: Shelly M.Milano q , Date of Inspection: 12/15t2006 �y SKETCH OF SEWAGE DISPOSAL SYSTEM 000�S 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. 74 Vj fell 61 10,11 10 Cl- i / 1 7 Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 Ansel Howland Road,Centerville,MA Owner: Shelly M.Milono Date of Inspection: 12/15/2006 j SITE EXAM _ Slope Surface water Check cellar ,�y�� CJ�� '�� fty Shallow wells J Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) C ecked with local Board of Health-expl�2 ain: ecked c with local excavators,installers-(attach documentation) Acessed USGS database-explain: � G �!2�= � �.'f�0� � �v� You must describe how you established the high ground water elevation: Z , J 14- ll Ig 5 TOWN OF BARNSTABLE n-S-el 1iwlow R---,&/ SEWAGE # LaCATON V*LLAGE Can` s'Vol ASSESSOR'S MAP &LOTZ INSTALLER'S NAME&PHONE NO. 1}�Sjr�Y.c�yY�-t. ) 411v3 6�_ C SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ' -T`Y, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells a ist. 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 IliAl f fflw 5 ? � RECEIVED OCT 0 12003 COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS_ HEALTH DEPT. z w DEPARTMENT OF ENVIRONMENTAL PROTECTION W A � d I- C I p�M Syev TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 2 Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner's Name: ARLENE RICHARDS&ELISE BROWN Owner's Address: 195 ANSEL HOWARD RD.CENTERVILLE, MA 02632 Date of Inspection: 9/8/03 Name of Inspector: (please print) JOHN GRACI,INC. ft Company Name: SEPTIC INSPECTIONS COP Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 1 certify that 1 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: 9 X Passes ! _ Conditionally Passe _ Needs Further Eval ` bn by the Local Approving Authority Fails Inspector's Signature: Date: 9/8/03 The system inspector shall submit a copy of is inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the stem 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. Title. S Tncnantinn Fnrm 611 S/ 000 1 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 195 ANSEL HOWARD RD.CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 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 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 n/a "This system passes if the well water analysis,,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forim. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 195 ANSEL HOWARD RD.CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS& ELISE BROWN Date of Inspection: 9/8/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 %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 NnT IN THE LAST YR.- X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system 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. 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) 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 i 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 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. i 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 195 ANSEL HOWARD RD. CENTERVILLE, MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up '? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum `' X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems `? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: 'Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is :unacceptable) [3 10 CMR 15.302(3)(b)] a t 1 t ' S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 195 ANSEL 140WARD RD.CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS& ELISE BROWN Date of Inspection: 9/8/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):X`a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): 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/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YR. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: .1999 PER PERMIT#99-677 'Were sewage odors detected when arriving at the site(yes or no): NO h Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: H 10' 6" H 5' 7" W 5' 8`1 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: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): n/a "' Page 8 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE 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 R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON LEACHING leaching chambers, number: 2 CHAMBERS leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE CHAMBERS,PROBED DRY.THEY APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. CHAMBERS WERE EMPTY AT TIME OF INSPECTION. BOTTOM IS AT 4 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a 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 4 i Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 195 ANSEL HOWARD RD. CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 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. w P - }3 �I F-Ool 1 F o MCI S�-F 6A 20a in Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 195 ANSEL HOWARD RD.CENTERVILLE,MA 02632 Owner: ARLENE RICHARDS&ELISE BROWN Date of Inspection: 9/8/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. r 11 i TOWN OF BARNSTABLE ` LOCATION ���.��/V ��' ��4���/�':'-�� SEWAGE # / r VILLAGE f.�- L' - ASSESSOR'S MAP & LOT l INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUMDER OR OWNER PERMITOATE: ), COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the/11ity7f of Leaching Facility Feet - Private Water Supply Welland Leaching F any wells exist on site or within 200 feet of leachin cility) Feet Edge of Wetland and Leaching Faci ' (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �Y� I No. �( J� 7 Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Mtopotal *potem Com6truction 30errnit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components 19a °Ari essf Howland. Rd.. , Centerville ° 'ra '�'` f Y'� °' Assessor's Map/Parcel - Ss. L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil k� Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system D-box and 2 precast chambers w 4' of stone , all,around. 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 b Bo of Hea . Signed Zj Lg Date U Application Approved by - ' Date Application Disapproved for the following reasons Permit No. Date Issued C) " ISM ., 4:7 f 4NO. �F g47 � / Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ✓" PUBLIC HEALTH DIVISION - TOWN-OF BARNSTABLE., MASSACHUSETTS ZippYtcatton for Mtgoml *pgtem Com6tructton Vermtt Application fora Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components f j9 oVddresl°tWowland Rd.. , Centerville Assessor's Map/Parcel i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan.Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S cc Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system D-box and 2 precast chambers wl 4' of stone, all,around.. Date last inspected: Agreement: —4 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 tp Bo d of Hea ° Signed b 1 Date ZO—1,5 4 Application Approved by - r - Date/6,'/-f—' f - Application Disapproved for the following reasons i Permit No. / 7 Date Issued /C) -----; --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Cullotta BARNSTABLE, MASSACHUSETTS Cerftftcate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 195 Ansel Howland Rd. , Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9I 1'4 77 dated /oZr_,? Installer Wm. Robinson Sr. Designer 1 t The issuance of this e t shallriot be construed as a guarantee that the,system`will functionAls designed Date ;lr`,C l51 -! InspectorA � — --------------------------- — No. / 7 Fee $5Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Cullotta Btgpo!5ar *p�tem Con5tructton Vermtt Permission is hereby granted to Construct-(''')Repair(X )Upgrade( )A,b ff on( ) System located at 195 Ansel, Haw�'and,,•t .,,,, uentervi e 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:Constructio must b Ccompleted within three years of the date of thi it. �� Q Date: ��S / / Approved by ^�x y � i r 1/6/99 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 DESIGNED PLANS) I, William E . Rob ins on,S,rhereby certify that the application for disposal works construction permit signed by me dated to g , concerning the property located at 195 Ansel Howland --Id-. , Centerville meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or busiiiets uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within too feet of the proposed septic system _ There are no private wells within 150 feet of the proposed septic system (.� There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the mwdmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, f Please complete the following: ) A) Top of Ground Surface Elevation(using GIS information) / t B) G.W. Elevation +the MAX High G.W. Adjustment . DJFJ�EEtENCE BETWEEN A and B SIGNED . �/(/ I Ll DATE: JSketch pressed plan of system on back]. q:health folder:cen f Z :. ��� . � J b�� . 4^ TOWN OF BARNSTABLE t LOCATION/� �- /V ��'` /�c,C �i:p SEWAGE # 7 VILLAGE tom-. L'w I a -ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.SEPTIC TANK CAPACITY AQ-12� LEACHING FACILITY: (type) gX7- (size) /NO.OF BEDROOMS BUILDER OR OWNER C'G 7rA PERMTTDATE:/0-0-5 1 COMPLIANCE DATE:/6 " --. Separation Distance Between the: Maximum Adjusted Groundwater Table to the/11ivo m of Leaching Facility Feet ' Private.Water Supply Well and Leaching F (If any wells exist -on`site or within 200 feet of leachin cility) Feet .Edge''of Wetland and Leaching Faci ' (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Lot ; I, C0.11114\7WEALTH.OF MASSACHUSETTS ExECU TIVE OFFICE OF E:N'VIRO\MEN TAL AFFAIRS E DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE R'INTER STREE':. BOSTON Kk O21Oc (617) 292-550t, TRUDY COX. Secre;a-. ARGEO PALL CELLUCCI DAVID B STP. 'I'.S Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTA CERTIFICATION Property Address: 195 Ansel Howland. R d.. Narne of Owner Mr . Culotta C ent ery lle Address of Owner: Date of Inspection: /() Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerq inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CompartyName: Wm. E . Robinson Septic Service Mailing Address: PO BOX 10 9. Centerville , MA Telephone Number: 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: 1/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails i Q Inspector's Signature: Date: J The System Inspector shall submit 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 CDEi 3 1999 NS - - DEPT. cam. revised 9/2/98 PaFe•1of11 i� P.orted 0n Recydrd PaIn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) iopertyAddress: 195 Ansel Howland. Rd.. , Centerville 0- Culotta Date of Inspection: INSPECTION SUMMARY: Check C, or D: A. SYSS PASSES: 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. COMMENTS: B. S TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate ye no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. 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. 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 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 The system required pumping more than four times a year due to broken or obstructed pipels). 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 Page 2of11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropenyAddres��ss: 195 Ansel Howland. Rd.. , Centerville Own er: Culotta. Date of Inspection:/0..vZjl_9 9 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 CIMR 15.303(1)(b)THAT THE SYSTEM 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. 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 (approximation not valid). 3) OTHER revised 9/2 98 P2gc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A r CERTIFICATION Icontinued) ProWWAddress:195 Ansel Howland. Rd.. , Centerville Owner: Culotta Date of Inspection:16���j'_9 3 D. SY 7* dicate FAILS: You mu either "Yes or "No" to each of the following: ve 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 Backup of sewage into Iacilityor system component due to an 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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. LARG SYSTEM FAILS: You must i dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater ILarge System) and the system is.a significant threat to public h alth and safety and the environment because one or more of the following conditions exist: Yes o 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of th Department for further information. revised 9/2,/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 195 Ansel. Howland. Rd.. , Centerville Owner: Culotta Date of Inspection: G 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ 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. ° _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. 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: _ Existing information. For example, Plan at B.O.H. 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)) _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintana-- f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C ` ' SYSTEM INFORMATION 'rop"Address: 195 Ansel Howland. Rd.. , Centerville Owner: Culotta Date of Inspection:66— e 9 FLOW CONDITIONS RESIDENTIAL: Design flow: 'r- O g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flow 2s0 A Number of current residents: Garbage grinder(yes or no):A- Laundry(separate system) (yes or no):/L�Q; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):Xi Water meter readings, if available (Iasi two year's usage (gpd): 1998 112, 000 gal. Sump Pump(yes or no):/�G 1997 112, 000 gal. Last date of occupancy: fo���- 9 COMMERCIAL/INDUSTRIAL: Type o establishment: Design ow: ypd 1 Based on 15.203) Basis of design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-tatof iry waste discharged to the Title 5 system: (yes or no)_ Water readings, if available: Last f occupancy: OTHescribe) Last occupancy: GENERAL INFORMATION PUMPING RECORDS and s urce of information: System pumped as part of inspection: (yes or no)�G d If yes, volume pumped:/.S'6 4 gallons Reason for pumping: TYPE OF YSTEM OF 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 APPROXIMATE AGE of all components, date installed(if known) and source of informationJd"-1;�s—51 �J Sewage odors detected when arriving at the site: (yes or no)LL revised .i/2/Q.c Page 6(if 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(ewitinued) 'ropertyAddress: 196 Ansel Howland. Rd.. , Cemterville Owner: Culotta Date of Inspection: BUIL G SEWER: (Locate n site plan) Depth)beow grade:Materf construction: cast iron 40 PVC other (explain) Distanrom private water supply well or suction line DiameComms: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK:_ (locate on site plan) t Depth below grade: — — — Material of construction: oncrete metal Fiberglass Polyethylene_other(explain) If tank is metal,list age_ Wage confirmed by Certificate of Compliance_(Yes/Nol / r� Dimensions: U` r + Leo Sludge depth: r Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 s r Distance from top of scum to top of outlet tee or baffle:y{� t Distance from bottom of scum to bottom of outlet tee or baffle:�L How dimensions were determined: 'omments: (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.) cl G GREAS TRAP: (locate o site plan) Depth bel w grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scum thick ess: Distance fr m top of scum to top of outlet tee or baffle: Distance f om bottom of scum to bottom of outlet tee or baffle: Date of I t pumping: Comme ts: (reco endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) J�rop"Address: 195 Ansel Howland. Rd.. , Centerville Owncr: Culotta Date of Inspection: /d oU- 91 TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth b low grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design flow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Date f previous pumping: Com ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,.evidence of solids carryover, ev dd f leakage into or out of box, etc.) - PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms in working order(Yes or No) Commen s: (note c dition of pump chamber, condition of pumps and appurtenances,etc.) revised 9/2%98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION(continued) 'roperty Address:195 Ansel Howland. Rd.. , Centerville owner: Culotta Date of Inspection: U, S—9 7 SOIL ABSORPTION SYSTEM(SAS):_V (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: - - leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of sal, signs of hydraulic failyre, level of ponding, damp soil, condition of vegetation, etc.) o � S CESSPOOLS:_ (locate on site plan) Number and configuration: rL Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: its Y' Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comme s: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate site plan) Materi Is of construction: Dimensions: Dept of solids: Com ents: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revises 9/2!96 Pagc9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) "bropertyAddress: 195 Ansel Howland Rd.. , Centerville JWnef: Culotta Date of Ins on: 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) _ 3 I revised 9;2/9? Page 10of11 a� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION Icor>tinued) rop"Add►ess:195 Ansel Howland. Rd.. Centerville Ownw: Culotta Date of Inspection: /dam q NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 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 --V—/Checked with local Board of health Checked FEMA Maps - Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) A revised 9/2/96 page iiortl 1 a � cc �.J Q -J 1A CAT ION ©ry S E W A G E PERMIT NO. Lot 5 Ansel Rd. Cent. 82-659 VILLAGE Centerville, M,asa. (--H I N S T A LLER'S NAME i ADDRESS Robert B. Our Co. Inc. Great Western Rd. forth Harwich. Mass. S U I L D E R OR OWNER Alan Small DATE- PERMIT ISSUED 11/9/82 DA-T- E COMPLIANCE_ ISSUED /�� >-.. - � . ��f J� � � . . YA ►�` � ��������� ^ THE COMMONWEALTH oF MAssAoxuscrTs U����� ���� ����^"" ~�� " --..��.u�^-n���w��-��F-' ------------ 0� .° ��� �~°° ��^ �� ��L~°�� ^��~ �������� ��� �1������ ����m� ��mitrurtion jJrrnfit Application is hereby made for u Permit to Construct ( ) or Repair ( ) an, Individual Sewage Disposal 3Syat: --'--'---- or 4t --'--_-.~_-'_-------------_---------_--'--' --------_' -------------'--'-'_--' ----ur-�---~�p�--~-`---'--.................................. ---- -------''=��__-------'�~------------------------_ I"*"�, �aue" _~ Type of Building Size Lot...Z��A:�...Sq. feet Dwelling—No. of Bedrooms............3!...........................Expansion Attic ( ) Garbage Grinder ( ) � Other—Typeof Building -----------'-' No. of persons............................ Showers ( ) -- Cafeteria ( ) .� Other fixtures .-------__-.--_--_----__--'-_--- -._-_ Dru6go '�uDoos pccy�c000ycrdu�. Total du�v8o�-. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test ]leonita Performed by...................-��.............................................. Date........................................ Test Pit No. l................minuoeaperinch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 3................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...................................................... ...................................................................................................... 0 Description c6 Soil........................................................................................................................................................................ ...................................................................................................................................................................................................... .-------_---.----_'------_'__-------__.--.-__-----_-._--__'-----_--'--_---_---'----- U Nature of Repairs or Alterations--Answer when applicable.............................................-_--.--------,..................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual S D�o�u S��m � a�o�u�e �� the provisions of'J';T!LE 5 of the State Sanitary Code— The undersign rther agrees not to place the system in operation until a Certificate of Compliance has been is,4ue_q by the board ri,ealth. a/ ------'-------'----'--------'------'----'---'---'------------'---- ~^~ Permit Date | r No... Fps..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ....................OF.................................................................................... .._._. Applirtttion for Disposal Works Tonutrurtion "Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -••.............__----•-...................--•--............._._........----------•----------•-• -••---•-•---._.......---......--••---•----------•••-----------------------•--------._.........._.. Location-Address or Lot No. ................................................................................................. ..........__...................................................................................... Owner Address .....................•--.......•-----•-•--_._...•. Installer Address QType of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ......................... - -•------------------- ------•---------------------.................................... -__....... W Design Flow............................................gallons per person per day. Total daily flow..__.._......__...._..._............_.......gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------------: -- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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........................ a ---------------- •--------------------- -.... .---------- ••------------- •------------------- ------- -........ •------ -....... ._.._--------------------- ODescription of Soil........................................................................................................................................................................ W -----•----------••--------------------------------------------=-------------------------------------------•----------------------------•----------------------------------------------------•---•--_.... UNature 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'I' 1,;^. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. J.S I-P,ed_ ".......................•-•------------•----•-----------------•------.-._.....-- --• s Application Approved By----•---- i'-- t------------------------•-•--•-- Da __.._ Date Application Disapproved f o the ollowing reasons-.........................................................-........................................................ ----------------------------•-----•-•-------------------------------------•---------------------------------...---------------------------...--•---------•-----•-----------------------------_.._...--•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD/,5F HEALTH `..`..:... . ,r-...............OF....../.... t,¢� ,..9...-..-........ ..........._... z�,! ...' Tatifartt of Toutpltttttrr THIS, S ERTIFY, That the Individual Sewage Disposal System constructed ( r epaired ( ) by----- ' < ' j;;wt.............................. - ....... ; ----------------------- y _. - -- has been installed irk accordance with the pro�/tsions of TI'�LW� 5 of he State Sanitary Code esc • ed in the application for Disposal Works Construction Permit No.____. ,•_'' _ f __----------------_-- THE ---- dated----I `��f ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ZASAUARANTEE THAT THE SYSTEM W�XL SATISFACTORY. -/DATE. .._.` � ............................................................. Inspector_.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........... �,,� u�. g.?sr....... ............................. No......V �:'"°ry FEE.......J . Diupou , r s Tonutration rrutit Permission is hereb ranted t -•-----------------------------•-................................... g to Construct epair ( Indivl al--`5 ge D,• osal Systan •............... --- -------- --------- Street ` as shown on the application for Disposal Works Construction Permit No................c' -ate d.._ . . __.. ................... ll oard of H AliDATE----•------------••--------------------------14 .................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No Gh:�eAGE Gcz,No�cZ � DAiI.Y ,;;Low s 110 Y. 34 33oG.Ra _ t t:• SEPTIC, TAWK = 330x15(>% :-495G.P0- user 1006 015PoSAL PIT uSE 1000 GAL. S I DSVIALL AZSX _ ►5o s.A t 5o BOTTOM AREAS •. 4-!, (� rj O S.F.- X 1.O A �,0 •G.P. ExP D-so,c °' � � t!!, -TOTA t- DESIGN * 2 (a.P D. A�64 q- 5 TAN=. -ToTAL PA I L? FLOW 330 G.Po 4 +. o PE2COLATIOW RATES I IN ?-MIN OR.LE55• ��• r 32 t� �iK 56 , rrQZA AHD 6 ti , ' L MT { az; W. Jo s H { BAXTER Na 24048 CIL- , /ONAI �I9D $yR • ' o' ' 4•b r�=eI ; �7 � :. 's✓F3�lOII.. t� DIST. INV. r. INS! PIT Z I wmws o �{ 6TvN6 CERTIFIED PLo•T PL.At•l PROFILE LOLA-tIoW �EQTW-VIU-e No SGALE ScA.�E � i! �� •_ A_'1'E (�?.'�,l'Y�L Qo \A/ATEZ- p L A N REF Ev_EN GE % C.ERT►I=Y ?NAT THE �0��1DAT10i�5NovYN -- NEQEaN GoMPL`(5 LOT A►.tD SE'TbAGK GQVIEN 'TE F ' 7owm oW,2aDCO, 3R•(cMT'� FN 1; Ab1U ►s �Orj" -.6514TEIZVILL9 ul c..alJ LOGp►TED •WITIA FLoD LAIN D�►TE�-� BAxT62e WYE INC• R.E6 I ST F--QE'D 6 AN D'S u IZY icYoe'S 7"1s PL&W If? NOT gASt;v DId AN 03TFciZVILt.F'r • MASS• IW5T9_ufASW"V 4SU2VC--Y 4THE OF0.6ST5 1SW000 / un-T mc_ APPLICANT LA13 !�.>, ��.. L // //� � r/ /,� L 7