HomeMy WebLinkAbout0011 ELLIOTT STREET - Health 11 Elliot Street
Centerville
A= 230 123
UPC 12534 '
No.2�,_153 OR
MRs"ar
DATE
7/19/06
PROPERTY ADDRESS 11 Elliot street
Centerville
MA 02632
On the above date, the septic system at the address above was
Inspected.
This system consists of the following: 3�a�
1.1 1-1000 gaiion zept.ic' tank.,
2., 2-1000 ga.22on ie.a.ch.ing pits.,
Based on inspection, I certify the following conditions:
3o 7h.iz .ins a 7.itte Tv.ie zept.ie hyztem (78Code)
4., Septic zy,3tem .ins in paopea woak.ing oadea at the paezent
SIGNATURE
Name: Robert A.'Paolini
Company: Joseph P. Macomber & Son Inc
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
}
G.1
JOSEPH P. MACOMBER & SON,: INC.
Tanks-Cesspools-Leachfields
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 026.32-0066
775-3338 775-6412
x
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
;DEPARTMENT OF ENVIIi,ONMENTAL PROTECTION
d
TITLE 5
OFFICIAL INSPECTION FORM—.N-OT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFICATION :
Property Address: ..1 1 Elliot Street
Centerville MA 02632
Owner's Name: Elliot Anderson
Owner's Address: Same
Date of Inspection: 711 q f n r,
Name of Inspector: (please print RRb rt A o.l"ini_:_.
Company Name: 7_ !. acomlilt .Ion Inc.
Mailing Address:
Cen ezv,.c e, a�sb. OZ632
--__ Telephone Number: 5 0 8-7 7 5=3 3 3 8
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.13 340 of Title 5(310 CMR UAW). The system:
XXXPasses --
;Conditionally Passes
Deeds Further Evaluation by the Local Approving Authority
AaWi
Inspector's Signature:
~ Date:
The system inspector sha11 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.
Title 5 Inspection Form 6/1.5/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION:.FORM-NOT FOR YOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL .YSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 11 Elliot Street ,
Centerville MA 02632
Owner: F1 1 i nt Andprcnn
Date of Inspection: 71191 a 6
Inspection Summary: Check A,B,C,D or E/ALWAYSleomplete all of Section:D
A. System Passes: //ES
NO I have not found any information which indieates`that,any of the failure criteria describeTin 310 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
Septic zuz-tem .ins in /2ao/2ea wo.ak.ing o/ide2 at .the /2aeaent .t.imeo
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass"aection need tobe.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.
NO The septic tank is metal and.aver 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,�s;approved by.theBoard 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:
NO Observation of sewage backup'or break out or high static water level in the distribution box due to broken or
obstructed pipes)or duo 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:
NO 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:
2.
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 Elliot Street
Centerville MA 02632
Owner: Elliot Anderson
Date of Inspection: 7 1 9 0 6
C. Further Evaluation is Required by the Board of Health:
NO 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:
no Cesspool or privy is within 50 feet of a surface water
no 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:
no The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.ofa
surface water supply or tributary to a surface water supply.
rzo The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
no The system has aseptic tank and.SAS and the SAS is within 50 feet of a private water supply well.
no The system has a septic tank and SAS and the SAS is less than 100 feet but 5Lfeet or more front a
private water supply well**. Method used to determine distance vizua-e
**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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address: 11 Elliot .Street
Centerville MA- 02632
Owner: Elliot Anderson
Date of Inspection: 711 9/0 ti
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the followingfor all inspections: .
Yes No
Backup of sewage into facility or system component due.to overloaded or clogged SAS or cesspool
_ Discharge-or.ponding of effluent to the surface of:the.ground or surface:waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded,or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than%.day flow
_ 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.al Zone l 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..[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 triggere&A copy.of the analysis must be attached to this forlp.]
(Yes/No)The system fails,I have determined that one or.more�'ofthe 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 1.01000 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 s' ,
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST .
Property Address: 11 Elliot Street
Centerville MA 02632
Owner: Fllint Anderson
Date of Inspection: 7/19 0 6
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?
N1 R_ 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 componentsp&xcluding 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
y Existing information.For example,a plan at hie 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)[310 CMR 15.302(3)(b)]
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 Elliot Street '
Centerville MA 02632
Owner: Elliot Anderson
Date of Inspection: 7/1 9/0 6
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms)` 4.4 0
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n o
Is laundry on a separate sewage system_(yes or.no):n o [if.yes separate inspection required]
Laundry system inspected(yes or no): n o
Seasonal use:(yes or no): no, 2004=108, 000 ga2$ons qi)D 295o89
Water meter readings,if available(last 2 years usage(gpd)):2 0 0 5=116, 0 0 0 ga- -Q o n,3 G%D=317.t 8.1
Sump Pump(yes or no): n o
Last date of occupancy: /?2 e e n t
COMMERCIA,L/IN'bUSTRIAL N1R
Type of estabWbixient:
Design flow(based on 310 GMR 15.203): �pd
Basis of design'flow(seats/persons/sgft,etc.):.,
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/use: .
OTHER(describe):
GENERAL INFORMATION
Pumping Records N�,4
Source of information: -.
Was system pumped as part of the inspection(yes or no): n o
if yes,volume pumped:_gallons How was quantity pumped determined?
Reason for pumping:.
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption.system
_Single cesspool
Overflow cesspool
—ivy
_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 age of all components,date installed(if known)and source of information:
33 yea2z
Were sewage odors detected when arriving at the site(yes or no):2 o
6
Page 7 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Elliot Street
Centerville MA 02632
Owner: Elliot Anderson
Date of Inspection: 711 Q.16 6
BUILDING SEWER(locate on site plan)
Depth below grade: 3.0"
Materials of construction: cast iron _40 PVC other(explain):cast .iaon to i2ght weight
Distance from private water supply well or suction line: 2 0 t
Comments(on condition of joints,venting,evidence of leakage,etc.):
Zninjn npponn f,;ghf , Nn Pprikriyo von}or/ lhnnugh hott.ia yn.n.t
SEPTIC TANK:y e_.s(locate on site plan) 1000
Depth below grade: 2 4"
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: 8' 6"X5 ' 8"X4' 10"
Sludge depth:_ 2 a c e
Distance from top of sludge to bottom of outlet tee or baffle: to a c e
Scum thickness: t 2 a c e
Distance from top of scum to top of outlet tee or baffle:t a a c e
Distance from bottom of scum to bottom of outlet tee for baffle: /t a c e
How were dimensions determined: measuzed
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence ofleakage,etc.):
Pump .tank eve2u 2 uea/th Zniet R otitiet teen aze .irz=Reaceo
Za i. iA .ctnurtunnOPg .round
GREASE TRAP:NQ(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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
G2ease tltap iz not 12ae6ent
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: 11 Elliot Street
Centerville MA 02632
Owner: 'Fllic)t Anderson
Date of Inspection:_711 91 p 6
TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan)
)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):.
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Continents(condition of alarm and float switches,etc.):
T.igh.t olt tankz ate not /2,ce sent
DISTRIBUTION BOX: No (if present must be opened)(locate on site plan)
Depth of liquid level above outlet,invert:
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.):
Diat2.igut.ion Pox t.3 not 122e6ent
PUMP CHAMBER: NO (locate on site plan) ——
Pumps in working order(yes or no):
Alarms in working order(yes or noj:
Comments(note c�ndition of pum chamber,condition of pumps and appurtenances,etc.):
l um/2 C am e2 Lb n0 pae%en
8
Page 9 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 Elliot Street
Centerville MA 02632
Owner: Elliot Anderson
Date of Inspection: 7/1 9/0 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If�AS not located explain why: _^
oca ed zee page
Tye
leaching pits,number: 2
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.):
Loamy to medium .6and., No zi.gaz of ,ea.i&,se zo.iiz ate day.i No
/lon sago ege a.t.ion .i-6 , nolLmai.,
CESSPOOLS:NO. (cesspool must be pumped as part of inspection)(locate on site.plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer: _
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes`or no):.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
CeasRooiz ate not 2,sezent
PRIVY:NO (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.):
l a iV�y i,s not 122eZen.t
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUB§7ACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
(\ PART C.
SYSTEM INFORMATION,(continued)`
11 Elliot Street
Property .
I P rtY Address.
_ Centervi-11P MA 02632
Owner: P1 1 i nt Ana,-rso11
Date of Inspection: 7.41914 n 6
SKETCH OF SEWAGE DISPOSAL SYSTEM
Pibv�de a sketch of the sewage disposal system including ties to at least two permanent i'efer~ern:e landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the buiWfng.
fi1�l °Yt v t Lbe,
a3
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FART.0
SYSTEM INFORMATION(continued)
Property Address.. 11 Elliot Street
Centerville MA 0263-2
Owner: Elliot Andersdri
Date of Inspection: 7/1 9/0 6
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:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
y e z Observed site(abutting property/observation hole within 150.feet of SAS)
Checked with local Board of Health-explain:a,s Aui.R.t e a 2 d no Checked4ith local excavators,installers-(attach documentation)
Accessed USGS database=explainhtt/R t town.'ga zaz t a g e.,ma.,ups
�--.. You must describe how you established the high ground water elevation:
U,6ed • Cape Cod Commzzzon Natea 7agie CoritOu2i3 And l uatie lJa.tea SuRp.2y
Neii head protection a2eaz map.- Sept I995
I at ea aehoaace.s o .ice cape cod comm.iz ion.,
Top of Ground
Leaching
Pit feet
Groundwate 'feet Below Bottom P'f p� o Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
0 .
Therefore,the vertical separation distance between the bottom —+"
Of the leaching pit and the adjusted groundwater table is
feet.
11
loom
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TOWN OFBARNSTABLE BOARD QF ALTII V
SUIISURFACR 899-AGE DISPOSE SyVa ItISPECTION FORM - PART D CERTIFICATION
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-TYPE on PRINT cum y—
PRO,PERT y MSPFCTEV
STREET ADDRESS 11 Elliot Street Centerville 0263.2
A•SS•ESSORS MAP, DLWK AND 'PARCE1
OWNER's NAME Elliot>-.Anderson
PAIiT'" D 0F1i1'IFI0AT3ON
NAME 'OF INSPECTOR Robert A Paolii -
• � i i.i ,www�w�wiw�wwpwr� w'www��
COMPANY NAME macornh6j 'on
COMPANY ADD.RSSS �' ' fox `:66 -C nto_rville MA' Q2632-0066
sts• I. TO •or City. - .Sta •. zip
COMPANY TE69PHONE t 508. Y�7.5 3338 FAX (' 508 , '90 f578
n.s.,.r.....ww....����..
CERTIFICATION. STATEMENT
I certify that I have persolial-ly .inspeoted .the 06wage 'ditipopil. 870tem at
this address and that- :tb'ee information reported ,is true,. soCurate•, and
omplete as of the time gf*�inspeotion.,- The in Peotiorn was per•fo:rmed and any
recommendations regard.itig .upgrade•, .ma•intenance ,' abd repair *rp. eongis'tent
with my trainikj% snd exP.e'rience in the ppoper function- grid maintenance of on-
site sewage disposal systems,
Check one;
Systeoi PAS9*D
The inspection whic.h.•J. have .conducted has .,n-ot 'round any, information .
which indieateg that. the system' fails to ' adequately. protect .public
health or the envi,.ropment as defined iri• .310 CMR. -Any failure
criteria *6b evaluated* are as stated in the FAILURE' CRI'i'MA .eeetioin of
this form.
System FAILED* }
t The inspection which I have 0O' bdobted 'has-1ound that the System fails to
protect the �ublic health and the enV ronmen•t ' in acoord•anee with Title
61 310 CMR 15 . 303, and as • speei f ically noted .on .PART' C -. FAILURE
CRITERIA of this inspecti n rm
Inspector Signature' •
Date
ne' copy of this oerti f ios;t•f-*n 1i u'et -be grovIded :to : the .QWH9R•I th'e BUYER
where appikoeble) and thin DgARD, OV HEALTH
'
* If the inspection FAIL•Eb,j thb .ownel''.ox "operator •e:h*1j . upgri,4e'•the system.
within one year of the da't•e of the inapeetiont unless, allowed Qr• regli,red -
nth,krw{ae. as provided in q,1,0 CMR 15 ,3061.
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Edge of Wetland and Leaching Facility(If any wetlands exist
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