HomeMy WebLinkAbout0223 ELLIOTT ROAD - Health 223 ELLIOTT RD., CENTERVILLE
A =
0
A
I
i
I�
r
f
au •
UPC 12534 '
&153�R +4�r
� 1tAYTi11W�YN
i
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r DEPARTMENT OF ENVIRONMENTAL PROTECTION
w
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SMEl'�TS ?
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ra
PART A
CERTIFICATION
Property Address: 273 Elliott Road IM IV
Centerville
Owner's Name: J. White
Owner's Address:
Date of Inspection: 10/13/2005
Name of Inspector: (please print). Patrick T. Sullivan
Company Name: Ready Rooter
Mailing Address: P.O. Box 371
Sandwich,MA 02563
Telephone Number: (508) 888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
,,,,"Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: �' �"— u�� ,�1 Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
C. System Passes:
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:
^TC% A,.A
B. System Conditionally Passes:
One or more system components as described in the"Coditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or�epair, 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.
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:
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,se..tiled 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:
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):
r
r` broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
C. Further Evaluation is Required by the Board of Hea
Conditions exist which require further evaluation y the Board of Health in order to determine if the system
is failing to protect public health,safety or the enviro ent.
1. System will pass unless Board of Health etermines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner hich will protect public health,safety and the environment:
_Cesspool or privy is within 50 f t of a surface water
Cesspool or privy is within 50 eet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Wate'r 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 SA'S 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
r
"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.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
,/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is 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.]
—X (Yes/No)The system fails. I have determined that one or more of the above 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�y�thadesign 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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question,in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system as 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
-�ZWere any of the system components pumped out in the previous two weeks?
_,Z-_ Has the system received normal flows in the previous two week period?
_ZHave large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different than 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
2/ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_�3_ Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):_)6f 5
Is laundry on a separate sewage system(yes or no):A-7-----�f if yes separate inspection required]
Laundry system inspected(yes or no):_ ,,,, *� ,--
30'3
Seasonal use: (yes or no):N27t:, ,W QC5:3=
Water meter readings, if available(last 2 years usage(gpd)): ;Pcj=Ak
Sump Pump(yes or no):e.-DC3
Last date of occupancy: !�y tiY� i3
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgfl,e
Grease trap present(yes or no):—
Industrial waste holding tank presen yes or no):_
Non-sanitary waste discharged toft� Title 5 system(yes or no):_
Water meter readings,if availa}le:
Last date of occupancy/use: r
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: �c��.� � -- �y�,,,, „��Q �„�� _ �C
Was system pumped as part of the inspection(yes or no N3cZ)
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
OF
tank,d�rl , 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):
Approximate ages of all components,date installed(if known)and source of/information:
Were sewage odors detected when arriving at the site(yes or no):,t�
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
BUILDING SEWER(locate on site plan)
Depth below grade: - 13 "
Materials of construction:_cast iron v140 PVC_other(explain):
Distance from private water supply well or suction line: .z, la.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: Azlocate 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: ,'? X l{•5,
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: --'S k"
Scum thickness: Y Q %,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: j r'
How were dimensions determined: �� vrrv. ,.,��•� -� "�L� �+�c-
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
� Vri a0 Z� c—��..l� : '� �`� � ` ,s�..: p�c�l^'�l F..a�� V\Lsl��•.1"�i "'v(
GREASE TRAP:_(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 tie or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
r
r
,rr
r
r
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
TIGHT or HOLDING TANK: (tank must be gum t time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fibe lass_polyethylene_other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day/
Alarm present(yes or no):
Alarm level: Alarm in workingr(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must'pened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distrib ion to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box, etc.): '
PUMP CHAMBER: (locate on site plan)
I'
Pumps in working order(yes or no):_yJ`
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
f,
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
SOIL ABSORPTION SYSTEM(SAS): ,(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumpe s part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: /
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater infl'P1w(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
/
3
PRIVY: (locate on site plan)
Materials of construction: e
Dimensions:
Depth of solids: /3
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
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.
r•" �
4 4
3
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 273 Elliott Road
Centerville
Owner: J. White
Date of Inspection: 10/13/2005
SITE EXAM
Slope
Surface water
Check cellar`,
Shallow wells
Estimated depth to ground water�feet
Please indicate(check)all methods used to determine the high ground water elevation:
�btained from system design plans on record—If checked,date of design plan reviewed:
bserved site(abutting property/observation hole within 150 feet of SAS)
_,.LChecked with the local Board of Health-explain:�,,-.__0,,�,.,n S'c , �z v 7` z 4,o�
Checked with local excavators, installers-(attach documentation)
,Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
'l�.� � r:�r�.�.a•Q r_� �.1`5��"�.1` y 'a-L� �i:Lh/�r 'lV�,tiz1 G `�vQ.J—. n.'"\�3T - �.^c��c S�:r �NX.-��u��. 1-d�r��=�--�0±.:�,r�r- S r car•,v�1�
i
DATE: 7/30/99
PROPERTY ADDRESS:223 ._Elliott Road-,- '
Centerville ,Mass .
------------------------
02632
------------------------
On the above date, I Inspected the septic system at the above. address.
This system consists of the following: Z (�
1 . 1-1000 gallon septic tank.
2 . 1—Distribution box .
3 .° 2—Flow Diffussors . 24 ' x 12 ' 4xl4"
Based on my inspection, I certify the following conditions:'
4 . This. is .a title five septic system. ( 78 Code )
5 .rThe flow diffussors are dry . /
6 . The septic system is in proper working order {
at the present time .
SIGNATURE:1
Name:_ _ Macomber �Tr ------
Company: Jose�h_P. Macomber_&�' Son , Inc .
^
Address:- Box-6 6'-----------_ zU
_Centerville , Ma . 02632-0066 " ro�ay0I99�
- ------- aRlr��
4
Phone: 508_775_3338----_-_
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
rJOS;E�PH P. �MACOIVIBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
I
fn ti.f
COMMONWEALTH OF MASSACHTJSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COX
Secrets
ARGEO PAUL CELLUCCI DAVID B. STRV -:
Governor Co:r_:_ss:oc.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
223 Elliott Road NameofOwnw Mike Scanlon
Centerville ,Mass . 02632 Addra"ofOwrw:
Data of 4upection:
Nam. of Inspector:(Please Prino Joseph P. Macomber Jr.
I am a DIEP approved systam 4upector purwarit to Section 15.340 of Tide 5 (310 CMR 16.000)
Company Name: Joseoh P. Macomber A Son, Inc.
M-IngAd&"4 2632-0066
Telephone Number: 9„0 8- 7 5-3 3 3 8
CERTIFICATION STATEMENT
1 certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below Is true. accurate
and complete as of the time of Inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on•slte sewage disposal systems. The system:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Failsof��l
inspector's Sigrsatlsre: Date:
The System Inspec hall bmit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin thirty (30) days of
completing Ws 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
Mall submit the report to the appropriate regional office of the Department or-Env4onmerual Protection. The original should be sent to ttx
system owner•and copies sent to the buyer, If applicable, and the approving authority.
NOTES AND COMMENTS
,
revised 9/2/98 Page Iof11
�� Printed on Recycled vspef
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 223 Elliott Road Centerville ,Mass .
owner: Mike Scanlon
Date of Inspection:7/3 0/9 9
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
I have not found any information which Indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
yd• 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 NO). 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
4 - The system required pumphtg-more than-four-times a yeardue to broken or obstructed pipe(s). The system wAt-pess--
Inspection if(with approval of the Board of Health): --
broken pips(s) are'replaced
obstruction Is removed
' revised 9/2/98 Page 2orn
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 223 Elliott Road Centerville ,Mass .
Owner: Michael Scanlon
Date of Inspection:7/3 0/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by tha 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.lMLL.PROTECT THE PUBLIC HEALTH.AND SAFETY AND THE BMHONMENT:
A.(') Cesspool or privy is within 60 feet-of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance .P�/� (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddro": 223 Elliott Road•' Centerville ,Mass .
Owrw: Michael Scanlon
Data of Irtspecidon:7/3 0/9 9
D. SYSTEM FAILS:
You must indicate either 'Yes' or 'No' to each of the following:
_ I have determined that one or more of the following failure conditions exist es 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 lailure.
Yes No A
L/ Backup of•sewage irnoiacllitY-or•vTetem component•clue%to m overloaded orcbgged•SASor•cesspod.
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 lev I in th distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
y Liquid depth In o*"aq Is less than 6' below Invert or available volume Is less than 112 day flow.
Required pumping more th 4 times In the Isst 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 60 feet of a private water supply well.
-� Any portion of a cesspool or'privy is less than 100 rest 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, ettach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen-and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either 'Yes' or 'No' to each of the following:
The following criteria apply to large systems In addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system Is within 400 feet of a surface drinking water supply
the system•Is-within 200 faetol�Nit>uteryioe wrfaoadririkksg wvate+suPplY ----
the system Is located In a nitrogen sensitive are&(Interim Wellhead Protection Area IWPA) or a mapped Zone II of a poor-c
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 turther Information.
revised 9/2/98 Peee4of11
I ) �
I
s�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddre:3: 223 Elliott Road Centerville Mass .
Owner: Michael Scanlon
Date of Inspectkm:7/3 0/9 9
Check if the following have been done: You must Indicate either "Yes" or "No" as to each of the following:
Yes No ,r
Pumping information was provided by the owner, occupant,or Board of Health.
_ None of the systemocorr*oarnts havaimen pumped4ovratJeest two%ve"s aadtha• ystem has&aea4sceiaiagwa"Aow
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,4 Cluding 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 teas, 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.occupaats. oi.if differa from.oxrner).weraprnuidad.awwith infnrrz,atiorinn ctio pm pp r�nta^ ^f
SubSurface Disposal Systems.
t
1
revised 9/2/98 Page 5orn
``((F
t�:l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4z
PART C
SYSTEM INFORMATION
ProponyAddreas: 223 Elliott Road Centerville ,Mass .
Owner: Michael Scanlon
Date of"'"action: 7/3 0/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedro m. n
Number of bedrooms(d� Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate System) ( es or�:—: If yes, Separatelrtspectlon.required -.
Laundry system Inspected ra or no)
Seasonal use (yes or no):
Water meter readings,If available (last two year's usage(gpd): "^ - <
Sump Pump (yes or no):A9f Zw
Last date of occupency: "�,*�h � CAW,
COMMERCtALANDUSTRIAL:
Type of establishment:
Design flow: .y cod ( Based on 16.2031
Basis of design flow ----
Grosso trap present: (yes or no)v2y A
Industrial Waste Holding Tank present: (yes or no)Aff
Non sanitary waste discharged to the Title 6 syste : (yes or no)A0
Water meter readings,If e I ble:
Last date of occupancy:
OTHER:(Describe)
Lest date of occupancy:__
GENERAL INFORMATION
PUMPING RECORDS a d sou ce f inforrnation:
A6 � ---
System pumped as part of inspection: (yes or no)
If yes, volume pumped: 11 gallons
Reason for pumping:
TYPE OFSYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
OW Privy
/17 Shared system (yas or no) (if yes, attach previous Inspection records,if any)
N I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank -��—Copy of DEP Ar.proval
Other —,—_
AQPROXJMATEA E f all components, datu i.istalfed{if known)-end sowco of4oformation:
Sewage odors detected when,arriving at the s:ta: (yes or no)
4
revised 9/2/98 Page 6of11
i
f
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMS
PART C
SYSTEM INFORMATION (continued)
PropemAddrass: 223 Elliott Road Centerville ,Mass .
OWTW: Michael Scanlon
Dou of Utispection: 7/3 0/9 9
BUU..DWG SEINER:
(Locate on sit+ plan)
1(
Depth below grade: 1� �
Material of construction; cast Iron✓40 PVC,_other(explain)
Ojs[ance from
jr(vats water supply well or suction line
Diameter_ _
Comments: (condition of Joints, venting, evidence of leakage,-etc.)
S K: ,
(locate on site plan)
/1
Depth below grade:,
Material of construction: oncrot.&metaUAFlberpiasW&Polyethylane /V&i other(explain)
If tank Is (natal,list age Ja.ago.conrumed by Cortlficats of Compliance (Yes/No)
Dimensions:
Sludge depth:,_
Distance from top llydge to bottom of outlet tea Orbaffla:�
Scum wcknosa: nl
Distance from top of scum to top of outlet tee or baffle: '1 n��
Distance from bottom of scum to bo om of outlet t s or baffle:
How dimensions were determinsd:
Comments:
(recommendation for pumping, condition of Inlet and outlet tee+ or•batfles, depth of liquid level In rotation to outlet invert' structurft 4ntaprity
evidence of leakage, etc.) PUMD tank PVPrY 1 9- outlet
and -jjt3gr
5o tnci Tank �o.al,t , nn o , mceFi�2— -enk i strur tall;
GREASE TRAP: t
(locate on site plan)
Depth below grade:,
Material of consUucdon:AA oncrsta4j&nst&PAFiberglass*APolyethylen*Qother(explain)
Dimensions:
Scum Wcknosa:
Distanco from top of scum to top of outlet tee or batfle:A
Distance from bottom of scum to bottom of outlet tea or baffle:
Date of last pumping:
Comments:
(rscommendation for pumping, condition of inlst and outlet tees or baffles, depth of liquid level In relation to outlet Invert. rtrucruraJ intapnty
evidence of leakage, etc.)
Grease trap is not present
revised 9/2/98 Paet7or11
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �.
PART C
SYSTEM INFORMATION (continued)
Prop*MAddra"223 Elliott Road Centerville ,Mass .
owrW: Michael Scanlon
Dau of Inspection:7/3 0/9 9
TIGHT OR HOLDING TANK:A&/0—(Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:N%T
Material of con3truction:49concrete Nmetalh&Fiberglass4 ,Polyethylene4,other(explain)
Alh
AJ _ _ -- --
Dimensions: Al
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order:Yes&A Nog)t
Date of previous pumping: A
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
ip, t or hol—di-nR tankq arP nntpresent .
DISTRIBUTION BOX:-/
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidenot of solids carryover, evidence of leakage Into or out of box, etc.) — —
Di stri httti nn buy her, 6i3Q Jvve£aj a )T9 evidence ossolid._
PUMP CHAMBER:
(locate on site plan) d
Pumps in working order:(Yes or No) /�
Alarms in working order(Yes or No)9
Comments:
Inote condition of pump chamber,condition of pumps and appurtenances, etc.)
ump chamber is not -p rPsAnt
revised 9/2/98 Page 8orII
I
f
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
6 PART C
SYSTEM INFORMATION (continued)
propeMAddre43:223 Elliott Road Centerville ,Mass .
Own,": Michael Scanlon
Dau of lwnspecliw: 7/3 0/9 9 ,/
SOIL ABSORPTION SYSTEM(SAS):JL ulred,location may be approximated by non-intrusive methods)
(locate on site plan, If possible, excavation not req
If not located, explain:
Type: ��nn
leaching pits, number:V ��
leaching chambers,number. }+
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool,numbs : `
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.
Loamto ffie-d.±aju -sand .
o si ns o cf. s i ry .
Ve
CESSPOOLS: uPi
(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 o1 Inspection)
ess o
Comments:
(note condition of $oil, signs of hydraulic failure,level of ponding,condition of•vegetation, etc.
ess,a
PRIVY: I�4All'.
(locate on site plan) N
AIA Dimensions:
Materjals of construction:
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Pr
revised 9/2/98
Pi¢e 9 or II
M '
i
.�
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM WFOR1.tAT)ON(condn+od)
PrW.nyAddrasa: 223. E11,:ott Road Centerville ,Mass .
Owr,w: Michael Scanlon
0"I of Lup.coon:7/3 0/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include tits to at le►st two permanent reference landmarks or benchmarks
locate ►il wells within 100' (Locate where public water supply comes Into house)
e•
L-J
i
J
t
revised 9/2/98 PQeglooru
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: 223 Elliott Road Centerville ,Mass .
owner: Michael Scanlon
Data of kupection:7/3 0/9 9
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:
_;ef<talned from Design Plans on record
bserved.Site(Abuttin ro on bservation hole, basemeot sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
01
C ocked pumping records
::/�Checked local excavators,Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Installed flow diffussors . 1988
9 ' to water
Diffussors are S ' off the water table .
40
revised 9/2/98 Page 11of11
t
1•r...n r•. -n.tR�Tr r.r.vnt.nnr•nn�nrrwn�.•+wwrr�w+�.nm nnr+v nnre�.n.rr. .. -I
'1'UHN OFBARNSTABLE BOARD OF 11EALT11 1
� e_.Tn.T••.;•.-T."n_.SUI)SU(tFACR 9FH�GF_DISPOSALSY9TF,M IN�9I'F�G~I'ION FORM - PART D^� CEftT! FIC�TIUN r-1i -•
-TYPE OR PRINT CI.EAALY-
PROPERTY INSPECTED
Centerville ,Mass .
223 Elliott Road Cent 'STREET ADDRESS
ASSESSORS MAP , BLOCK AND PARCEL `d'' �
OWNER' s NAME Micael Scanlon
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber- Jr.
COMPANY NAME Joseph P. Macomber & Son, Inc.
COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066
Street Town or City 5tat0 LIP
COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 _1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of.-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
System PASSED
The inspection iihich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have cona" cted has found that the system fails to
protect the public heal61 and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Dated l
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF 112AL1'il:
• It the inspection FAILED, the owner or"'oporator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 16 . 306 .
partd . doc