HomeMy WebLinkAbout0464 BAY LANE - Health 464 Bay Lane .
A = 157-065 Centerville
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UPC 17534
No. 2 53CORr
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TOWN OF BARNSTABLE
LOCATION `�� r " � SEWAGE # 0
VILLAGE 61ztiq Pia Oc� 1 8? GGJ ASSESSOR'S MAP 6
INSTALLER'S NAME & PHONE NO. A&r l/ /Gt -77 se&�
SEPTIC TANK CAPACITY /� 6 6
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
` BUILDER OR OWNER � ( m6
I
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
1006Y
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COMMONWEALTH OF MASSACHUSETTS \
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA RS \
DEPARTMENT OF ENVIRONMENTAL PROTECN !n',
ONE WINTER STREET, BOSTON MA 02108 (617)292 55 O ` (1.1
2��
14V CORE
% rt} ♦ ,`' Secretary
ARGEO PAUL CELLUCCI f�,,fIDAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 464 Bay Lane, Centerville, MA Name of Owner: Anne Haidas
Address of Owner: Sane
Date of Inspection: August 21, 2000
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, 0sterville, MA 02655-0049 Map:
Telephone Number: (508)862-9400 Parcel:
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:
✓ Passes
Conditionally Passe
_ Needs Further 1.va 1 do By the Local Approving Authority
Fails
Inspector's Signature: Date: August 23, 2000
The System Inspector shall sub 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
,
revised f9/2/98 t Page 1of11
1 P Printed on Recycled aper
r a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000
INSPECTION SUMMARY: Check A, B, C, or D.-
A. SYSTEM 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. 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.
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.
70Sewage-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
i .Health)
_ broken pipes)are replaced
obstruction is removed
distribution box is levelled or replaced w
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 464Bay Lane, Centerville, MA _ + mt ;s ,°•
Owner: Anne Haidas
Date of Inspection: August 21, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM 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 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 AND SAFETY AND
THE ENVIRONMENT:
-; 1 The system has a septic tank and,soil absorption system(SAS)and the SAS,is within 100_feet to,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 1 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 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"as 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 identi
fied below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or 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 '/2 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 l of apublic"well
_ portion of a cesspool or privy is within 50 feet of a^private water supply well.
An P PP Y
Y Po Pce P �'Y
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
coltform bacteria,volatile organic nitrogen and nitrate nitroen.c compounds, g g
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as 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
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 trapped 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 the Department for further information.
revised 9/2/98 Page 4of11
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000 :,• .
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 N/A.
✓ _ 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 conditions 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)
[15.302(3)(b)].
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas ,
Date of Inspection: August 21, 2000
FLOW CONDITIONS ;
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 1
Garbage grinder(yes or no): Yes
Laundry(separate system)(yes or no):No; If yes, separate inspection required
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available(last two year's usage(gpd): 1999-138,000 Qals.:1998-179,000 eals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Qpd(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no) _
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe) t
Last date of occupancy:
GENERAL INFORMATION
W".
PUMPING RECORDS and source of information:
Pumped on Nov. 19199 and Oct. 12195-per treatment plant.
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPRO.N MATE-AGE of•all components,date installed(if known)and source of information:. Pit was added in 1990-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 464 Bay Lane, Centerville, MA 0
Owner: Anne Haidas ,
Date of Inspection: August 21, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 16"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: . 2"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: Measuring stick
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 baffles were present The liquid level was even with the outlet invert. There were no signs of leakage.
Reconvnend installing risers to bring covers with 6"of grade
GREASE TRAP: None
(locate on site plan)
Depth below grade:
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:
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.)
.. .. • . nor'
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'-(continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection) ,
(locate on site plan)
i
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: Not fowid ;
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage.into or out of box,etc.)
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No) _
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pae8of11
revised 9/2/98 s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION. (continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000 :,a.t*,�•
SOIL ABSORPTION SYSTEM(SAS): ✓
(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: 2-6'x 6'
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 soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The older pit(0)was not dug up. The newer pit 04)is an overflow from the older pit 03), and was dry. The scum line was I'up from the
bottom. There were no signs of failure. The bottom to grade was approximately 8'. The pit was under a tree. Recommend installing a riser
before the roots and tree grow too big to access the cover. The cover is 20"below grade.
CESSPOOLS: None
(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(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY: None
(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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas
Date of Inspection: August 21, 2000
Map.
Parcel:
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)
GArAG ~
Al— 140
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Aa-
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14\3- 3�
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Ay , 5
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y
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 464 Bay Lane, Centerville, MA
Owner: Anne Haidas '
Date of Inspection:, ,. August 21, 2000 - � • -
MRCS 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
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was approximately 8'. Using the Barnstable topographic map and water contours map, the maps
were showing approximately 20' +/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high
groundwater adjustment for this site(Ml W 29, Zone C, 7/00) was 3.9'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
,ti T TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE C2;l erv,tLk ASSESSOR'S MAP & LOT/Fl7 ' Ob$�
INSTALLER'S NAME&PHONE NO.`
SEPTIC TANK CAPACITY /QM
LEACHING FACILITY: (type) P ITS (size) G x&
NO. OF BEDROOMS 3
BUILDER OR OWNER A n 11 N A 1 AA-5
PERMITDATE: COMPLIANCE DATE: `
Separation Distance Between the:
r.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility , Feet
Private Water Supply Well and Leaching Facility (If any wells exist
-.,on site or within 200 feet of leaching facility) Feet
v Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by v
Al- L0 co
&i- awl A� 3
A;L- L13.(o i
f3a- 34P, a O
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Aq- SJ 3
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Commonwealth of Massachusetts L
Executive Office of Environmental Affairs FRE ��v®
Department of 4 1997
Environmental Protection DEPT.RNSTABLE
William F.Weld
Gomrnor Seaway
Argeo Paul Celluccl David B.Struha
U.Gowrnor commbNorwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
CERTIFICATION
Property Address: 46//4 Bay Lane, Centerville Address of Owner. Jerry Gilmore
Date of Inspection: 2 _�g� -! (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8 )7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,aomrate
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:
�✓ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Y Date: I�_4�6-9
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] STEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indict yes,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, 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 ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-SM
401?Printed on Recycled Paper
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection:
Bj STEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstnucted 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 pipes). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C1 THER 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
blic health,safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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.
S) THER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM
PART A
CERTIFICATION(continued)
Property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection:
D) S FAILS:
I determined that the system violates one or more of the following failure criteria as defined in 310 CMA 15.303. The basis for
this etermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
fail
Backup of sewage into facility or 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 1/2 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
ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARD SYSTEM FAILS:
e following criteria apply to large systems in addition to the criteria above:
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:
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 U of a public
water supply well)
The r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req meats of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection: C p`Lp A 4
Check if the following have been done:
2Pumping information was requested of the owner,occupant, and 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 N/A.
facility or dwelling was inspected for signs of sewage back-up.
jZ'The system does not receive non-sanitary or industrial waste flow
!(lfhe site was inspected for signs of breakout.
i
system components, excluding the Soil Absorption System, have been located on the site.
4,/fhe 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.
size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
` (revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddroas: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection: 6-O'L g-q
FLOW CONDITIONS
RESIDENTIAL.• S
Design flow: y b aa'0.
Number of bedrooms
Number of current nts:,,]L_
Garbage grinder(yea or no)-A.- 0 _
Laundry connected to system(yea or no)1`'_Z��
Seasonal use(yea or no):_jLL—v
Water meter readings,if available: 1 9 9 5 - 1 0 6 0 0 0 a l s.
96 - 112 , 000 gals .
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
C Ate- # -a. Y z C' q S'
System pumped as part of inspection: (yes or no)__Z—O
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF 8 TEM
LeoSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information:l n d 1
a
Sewage odors detected when arriving at the site: (yes or no)-A10
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection: &—,2_o—aj
SEPTIC TANKY
(locate on site plan)
Depth below , � _
e'L-
Material of construction:vconcrete_metal_FRP_other(,:plain)
Dimensions: �C
Shtdge depth--
Distance from top of sludge to bottom of outlet tee or baffle:.?C!
Scum thickness: 2, ,
Distance from top of scum to top of outlet tee or baffler ►,
Distance from bottom of scum to bottom of outlet tee or baffle:-
Comments:
(recommendation for pumping,condition of inlet and out et tees or baffles depth of liquid level in relation to ou invert,structural integrity,
evidence of leakage,etc.) 0 -_ 7.4 +,. ! A, r
G TRAP:_
(locate on 'te plan)
Depth below e:
Material of nstruction:_concrete_metal_FRP_other(ezplain)
Dimensio
Scum ess:
Distance top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommen ton for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection: L - p- -7
TIG OR HOLDING TANK_
(locate site plan)
Depth grade:
Material construction:_concrete_metal_FRP—other(explain)
Dimeni ns:
Ca VRons
Desiga ow phone/day
Alarm 1 1:
Commen :
(conditio of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan) RR
Depth of liquid level above outlet invert: V
Comments:
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box,etc.)
PUMP C BER:_
(locate on si plan)
Pumps is rking order:(yes or no)
Commen
(note wadi n of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 464 Bay Ln, Centerville
Owner. Jerry Gilmore
Date of Inspection: _ /
SOIL ABSORPTION SYSTEM(SAS):,,
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:-Z—
leaching chambers,number:_
leaching galleries,number
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
Comments: note condition of soil s�f hydraulic f 'e, level of ponding,condition of vegetation etc.) $ f�
? t' ,
CESSPOO
(locate on si Ian)
Number and co tion:
Depth-top of to inlet invert:
Depth of of
yer.
Depth of scum yer:
Dimensions of pool:
Materials of oo on:
Indication of water.
infl (cesspool must be pumped as part of inspection)
Comments. (t condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PRIVY:_
(locate on site p )
Materials of oo ' n: Dimensions:
Depth of solids
Comments: ( condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
property Address: 464 Bay Ln, Centerville
Owner. Jerry Gi44 lmore
Date of Inspection: �,^a 0
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
y
n
Li
J
DEPTH TO GROUNDWATER
Depth to groundwater— J`� l�
method of determination or approximation: ► 6
(revised 11/03/95) 9