Loading...
HomeMy WebLinkAbout0120 FULLER ROAD - Health 120 Fuller Road, Centerville UPC 12543 No. 53LOR o+�S1•CON`'J�� HASTINGS, MN r � Commonwealth of Massachusetts /oGff W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name ; information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, ?' use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation V�,�yJi Company Name ! 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-17-17 _ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 tL o �1/f�� CAJ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in passing condition at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal,coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area Interim Wellhead Protection Y 9 Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CityFrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (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 from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015- 95,000gpd 2016- 115,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped spring 2016 Wass stem pumped as art of the inspection? Yes N Y P P P P ❑ ® o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): below Depth r 2$p o grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 2 (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a° 120 Fuller Road GSM Property Address P Y Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. I i Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Fuller Road Property Address Nancy W nd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.).- NA " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in passing condition when inspected. Liquid level was 13" below invert when viewed. Pit is full to approximately 5/6 it's capacity. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C A REAR B 1 2 3 4 A1-22' 131-28' A2-27' 132-23' A3-31' 83-19' 84-26' C4-43' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is Centerville Ma 02632 10-17-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >15'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: A previous inspection report showed groundwater to be greater than 15' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Info on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 120 Fuller Road Property Address Nancy Wynd Owner Owner's Name information is required for every Centerville Ma 02632 10-17-17 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �1 8 b Commonwealth of Massachusetts QD 'rfCEl �© my- Executive Office of Environmental Affairs �C17 Y Department of SAY 2a 1997 Environmental Protection rftorsm, Map: 1 HfA[Ty0 fPTAB(E ` William F.Weld Parcel: N Gw+ma Trudy Coxe s.u-d'y eo.0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM David B. Struhs PART A commissionor CERTIFICATION Property Address: 120 Fuller Road, Centerville, MA Address of Owner: Date of Inspection: May 22, 1997 (If different) Name of Inspector: James M. Ford Company Name,Address and Telephone Number: James M. Ford, P.O. Box 49, Osterville, MA 02655 (508) 775-7927 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 Passes Needs Further Evallation By the Local Approving Authority Fails 4 Inspector's Signature: Date: May 27, 1997 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: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR t5.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)M-SW C, Pnnled on Recycied Paper J d) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -; � PART A (� �` CERTIFICATION (continued) Eit Property Address 120 Fuller Road, Centerville, MA Owner:^S2 , Sp�r F Winston & Nancy Williams .Date of Inspection: May 22, 1997 B YSTEM CON A SDITIONLLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 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 APPROPRIATE) 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 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 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. (revised 8/15195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 Fuller Road, Centerville, MA Owner: F. Winston & Ahncy Williams Date of Inspection: May 22, 1997 D] SYSTEM FAILS (continued) 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and ►itrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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 Welhead Protection Area (IWPA) or a mapped Zone 1I of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 120 Fuller Road, .Centerville, MA Owner: F. Winston & Nancy WIliams Date of Inspection: May 22, 1997 Check if the following have been done: ✓ Pumping 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. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System, have been located on the site. ✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ✓ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. revised 8/t /9( 5 5) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 120 Fuller Road, Centerville, MA Owner: F. i-trinston & Mncy Wclliams Date of Inspection: May 22, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 Garbage grinder (yes or no): No Laundry connected to system (yes or no): Yes Seasonal use (yes or no): No Water meter readings, if available: Usage: 1996 - 145,000 gals.• 1995 - 151 000 gals Last date of occupancy: Presently oc=ied. COMMERCIALANDUSTRIAL- 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: Not ounmed since new system was installed per owner. 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: May 18194 per as built card. Sewage odors detected when arriving at the site (yes or no): No (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 Fuller Road, Centerville, MA Owner: F. Winston & Nancy Williams Date of Inspection: May 22, 1997 SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ concrete _metal _FRP _other (explain) Dimensions: 8'L X 4'6"W X S'D - 1000 Gal. Sludge depth: 2" 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: 12" 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.) Both inlet and outlet tees were in good condition. Liquid level was even with outlet invert No evidence gl leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _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: 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.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 Fuller Road, Centerville, MA Owner: F. Winston & Nancy Williams Date of Inspection: May 22, 1997 TIGHT OR HOLDING TANK: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP _other (explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Box was level and there were no signs ¢ solids carryover or leakage PUMP CHAMBER: None (locate on site plan) Pumps in working order (yes or no): Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM, INFORMATION (continued) Property Address: 120 Fuller Road, Centerville, MA Owner: F. Winston & Nancy Williams Date of Inspection: May 22, 1997 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: 1 (1000 gal.pit) leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) No signs¢bydraulichilure. Grass covers the system. 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 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 Fuller Road, Centerville, MA Owner: F. Winston & Nancy Williams Date of Inspection: May 22, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100'. c 1!3 J ds' 3 DEPTH TO GROUNDWATER: Depth to groundwater: IS +/- feet Method of determination or approximation: Barnstable Water Table Map USGS Topographic - Hyannis Quadrangle (revised 8/15/95) 9 I TOWN OF.BARNSTABLE V LOCATION1,a?(7 %,,11 7Z !?c/ , SEWAGE # VILLAGE �'ch,l��,// ASSESSOR'S MAP LOTf 9'gfg'V INSTALLER'S NAME PHONE NO. „ SEPTIC TANK CAPACITY /DDO LEACHING FACILITYAtype) (size) /pad NO. OF BEDROOMS L OR PUBLIC WATER Bit.B&R OR OWNER ✓ �,� '`� 2�1G- � � DATE PERMIT ISSUED: -.mil E DATE COMPLIANCE ISSUED: �•� ''> �J VARIANCE GRANTED: Yes No a �yl�C%2 �C� . • .. � � t , ` . %J, ' �:� � � � _�/,�i�\\j V \ V 1, APPROVED THE COMMONWEALTH OF MASSACHUSETTS B sta Conservati Depastme BOARD OF HEALTH TOWN OF BARNSTABLE Si red Date Allp iratinn fur Dig Vwial Midw Tomitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (XX)(an Individual Sewage Disposal System at: 120 Fuller Road Centerville ........................... .................................ill -Ad(jress or Lot No. Winston & Nancy Williams ......................-...........--- --•---•••-•------••-•-•--•-••--•--.........-•------------ -•---------•--------------••-•-•---•--••--•----•--•-•-----......-•-------•-••-----..........--.:.. oo ner Address W J .P.Macomber Jr . Installer Address Type of Building Size Lot............................Sq. feet V DwellingX No. of Bedrooms----------- ---•---------------------------Expansion Attic Garbage Grinder p� Other—Type of Building ............................ No. of persons.................--...--..-- Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width.............--- Diameter................ Depth................ x Disposal Trench—No. ............:........ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...........--....... Depth below inlet....--.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..........................................................--------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-----...........--.. Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit--.----..--------_- Depth to ground water......................--. 9 ----------------------- -•---------.......----------------------•--••-----------•----•-•-------•••••......................................................... 0 Description of Soil....................................................................................................................................................................... P4 Sand & Gravel U ----•--•---------------------------•-------------------------------•-------------------...........------------------------------------------------------•--•........................................... W ...-------•---------------------------------•-•----•---------------•-••-•..............••--------------------------•--------------••-•----------...---------------------------••----••----••---••----•- V Nature of Repairs or Alterations—Answer when applicable.-..-Omj:t - e e s so o o l s . Install 1-1000- gallontank1distri �ution box acYing f it. __. ___ _.__ __. g --le . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .. �.......4?12 .. 14......................... ........ ./..2/..g4....:...... Dare cy Application Approved By ------------ .......... ------------------------------------------- ......j L..-...1...��... Application Disapproved for the following reasonr: . .......... ........... .............................................. ........... . .... �j . ............................. ............... ...................................................................................... ........................................ PermitNo. ----------- .0---------------------- Issued ..... ....................................----....... ......... Dare -- ———————— ——————————————— J �V V - v-�+ .. i.J _-. .` V J .� - Lv_'_-U+ N•.......+ V r .�. tl -✓\.w". .-'4-.. - .r � J �. � ..�..� .y v +.. -- YJ `..-Z..J �•^.. 30 NO................. Rut- 00 1 - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH VCS' L � TOWN OF BARNSTABLE Appliratinn for Db3pwial Works C owitrnrtiurt Permit Application is hereby.made for a Permit to Construct ( ) or Repair (XX)f an Individual Sewage Disposal System at: 120 Fuller Road Centerville-----------•-•--....-- -•--••••--•--•------•----•--•--•-----•----------••--•-...---•------••......---•--•-•---•------•--- Location-Adtjress or Lot No. Winston & Nancy Williams .................................... .........._. ( O,cner Address W J.P.Macomber Jr. Installer Address d Type of Building Size Lot............................Sq. feet fDwelling X No. of Bedrooms........................................................____ - pansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- -------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity......_.___gallons Length________________ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by......................................•-•-••----••-•----•-•--••........... Date........................................ I a 14 Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ G 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Chi , a 0 Description of Soil......................................................................................................................................................................... W Sand & Gravel V -- -- -- ------------- - Instal 1 U Nature of Repairs or Alterations—Answer when applicable.____Omi�t Cesspools . 1-1-000._.ga•llon tank 1• distribution box 1-1000 gallon leaching pit. t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .... �1.�....../f�dJ//r�o :7./� ^?r... i7:��%........................ .......5.1.z/94...... G v Dare Application Approved BY .� Wit., .. �i .h -r�-.^-� --------------------------------------------- ----------- am Application Disapproved for the following re'.ions: ....._.............._...............--� .-- ............... . .. -......................---................... .......................... . ..... .• . ..................... .. • ....................................... '........... ........................................ Da PermitNo- ---------- ---------------------- Issued ...........................................................te Dare i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Eltifi ate of (11ompli2 nee THIS IS TO CERTIFY, That the Individual Sewage Disposal System.constructed ( ) or Repaired ( XX)j J.P.Macomber Jr. by ......... ............. ........................_. .......... Installer ---^* at .....120 Fuller Road Centerville ...... ... ..................................................................................................... .......... ...................... . ........ has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .. � .- ..(../.C_........... dated ._..................__..................._. THE ISSUANCE OF THIS CERTIFIC-ATE`SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............-............. .'....��., ............. Inspector ..........E ... ..-------- .-------- ..--------- ......... .. Z/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30.00 No....,/..�f.. �(/� FEE........................ Dish oal Work15 Tanotrudian "rrmit J. Permission is hereby granted..........P.Macomber Jr. to Con t uct ( ) or Re airX(XX an Individual Sewage Disposal System �10 Fuller koad Centerville atNo...............................................................................--• -•-•-•-•------.. -------------------•••---•--------------•-----•---- Street a as shown on the application for Disposal Works Construction Permit No`...r��� Dated..A_ 10.................... DATE----•-•---e, .......`-�L.. v Board of Health �-- ...............• FORM 36508 HOBBS et WARREN.INC.,PUBLISHERS