HomeMy WebLinkAbout0160 GLENEAGLE DRIVE - Health 160 Gleneagle Drive
Centerville P
A = 191 152 .
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UPC 12534
No. 2_ 153LOR
HASTINGS, MN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
4
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 160 Gleneagle Drive,Centerville,MA 02632 �s-
Owner's Name: Brian and Joanna Eddy z `
Owner's Address: 160 Gleneagle Drive,Centerville,Ma 57, 5 c
Date of Inspection: 06/16/2006
Name of Inspector:Reid C.Ellis
Company Name:Ellis Brothers Const.Co.
Mailing Address:23 Enterprise Road
Yarmouth Port,MA 02675 `
Telephone Number.508-362-6237
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 'on 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ��� 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.
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner: Brian and Joanna Eddy
Date of Inspection:06/16/2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. 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:
B. System Conditionally Passes:
One or more system components as described' the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replaceint nt 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
The septic tank is metal and over 20 years old* the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or ex6ltranon I r tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank a approved by the Board of Health.
*A metal septic tank will pass inspection if it is shuctur My sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is av ' le.
ND explain:
Observation of sewage backup or break out or gh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven Astribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are eplaced
obstruction is rem ed
distribution box is eveled or replaced
ND explain:
The system required pumping more than 4 tim a year due to broken or obstructed pipe(s).The system will
inspection spection if(with approval of the Board of Heal
broken pipe(s)are laced
obstruction is remo ed
ND explain:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner. Brian and Johanna Eddy
Date of Inspection: 06/16/2006
C. Further Evaluation is Required by the Board of H the
Conditions exist which require further evaluation the Board of Health in order to determine if the system
is failing to protect public health,safety or the environme .
1. System will pass unless Board of Health dete ' es in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surfai e water
Cesspool or privy is within 50 feet of a borde ring vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(ani I 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 absorpt on system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface wat supply.
The system has a septic tank and SAS and SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to dete a distance
**This system passes if the well water analysis, rformed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indi that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate ni gen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the must be attached to this form.
3. Other:
3
INSPECTION FORM-NOT FOR V
SUBSURFACE SEWAGE DISPOSAL SYSTEM ASSESSMENTS
M INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner. Brian and Joanna Eddy
Date of Inspection:06/16/2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes
ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
-/ col
4'
i uid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
times pumped
gortion of the SAS,cesspool or privy is below high ground water elevation
ortion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
supply.ortion of a cesspool or privy is within a Zone 1 of a public well.
ortion of a cesspool or privy is within 50 feet of a private water supply well.
ortion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to rrect the failure.
E. Large Systems:
/ A
To be considered a large system the system mustst rve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`des"or"no"to each of the llowing:
(The following criteria apply to large systems in addi on to the criteria above)
yes no
the system is within 400 feet of a surfacedr nldng 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 (Interim wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section the system is considered a significant threat,or answered
"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
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION I
PART B
CHECKLIST
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner: Brian and Joanna Eddy
Date of Inspection: 06/16/2006
rllowin have been done.You must indicate` es"or"no"as to each of the followin :
ping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
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,Atcluding the SAS,located on site?
Were the septic tank manholes uncovered,o n
of the baffles or tees,material of construction,dimensions,�'depth o liquid,interior d of the tank inspected for the condition
�P epth 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:
Y n
Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner. Brian and Joanna Eddy
Date of Inspection: 06/16/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): J 3
DESIGN flow based on 310 CI 15.203(for example: 110 gpd x#of bedrooms).
Number of current residents:
Does residence have a garbage grinder(yes or no): //b
Is laundry on a separate sewage system(y no)WO[if yes separate inspection required]
Laundry system inspected(yes no):
Seasonal use:(yes or no):_ a
Water meter readings,if av0ble(last 2 years usage(gpd)): 0
Sump pump(yes or no):,oV l/
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgketc.):
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 n
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records /
Source of information: —�z�'� / 1,ewe✓ 2�-- o
Was system pumped as part of the inspedi (yes or o):
If yes,volume pumped _L ons—How was quantity pumped determined?
Reaso for pumping: _
E 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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Appro e e o all ce rents, to ms ed(if known) so of info
Were sewage odors detected when arriving at the site(yes or no):A/0
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner: Brian and Joanna Eddy
Date of Inspection: 06/16/2006
BUELDING SEWER(locate on site plan)
u
Depth below grade: .3(91
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water or supply well suction I&C—
Comments-(on condition of jo g,evi cc. leakage,etc.):
!!2
SEPTIC TANK:0ocate on site plan) 6f
Depth below gradel�A--V'01-
Material of construction _concrete_metal fiberglass_polyethylene
other(explain)
A✓ tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) � 1` ��
Dimensions: mil/
Sludge depth:
Distance from top o sludge to bottom of outlet tee or baffle: 1 y
Scum thickness:e_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or b�.
How were dimensions determined:
Comments(on pumping recomme ,inlet&a outlet tee or baffie condition, integrity,liquid levels
related to et invert,eviden��1 ge,etc.): � � / 'cam
A '
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal fibe ass_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 e:
Date of last pumping-
Comments(on pumping recommendations,inlet and out t tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
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: 160 Gleneagle Drive,Centerville,MA
Owner. Brian and Joanna Eddy
Date of Inspection: 06/16/2006
TIGHT or HOLDING TANK: (tank must be r mped 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 o no):
Date of last pumping:
Comments(condition of alarm and float switches,etc
/'//�
DISTRIBUTION BOXY (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.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,cond lion of pumps and appurtenances,etc.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Gleneagle Drive,CenterviIIe,MA
Owner:Brian and Joanna Eddy
Date of Inspection:06/16/2006
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T,ype
eaching pits,number:_
leaching chambers,member: (/
leaching galleries,number:
Ieaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativetalternative system Type/name of technology:
Comments note condition of soil,signs of hydraulic failure,level
of ponding,damp soil,condition of vegetation,
etc. 0 &P' 07
!Y/t.�� y
H
X 1
CESSPOOLS: (cesspool must be pumped as part f 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 fat ure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
"/
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic fai'ure,level of ponding,condition of vegetation,etc.):
9
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Gleneagle Drive,Centerville,MA
Owner: Brian and Joanna Eddy
Date of Inspection: 06/16/2006
SITE EXAM
Slope
Surface water
Check
Shallow wells
c
Estimated depth to ground wa577-9 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
hocked with local Board of Health-explain:
�/Accessed
hecked with local excavators,installers- h docume ) vI✓_� ��
USGS database-explain: �f�.fa,AT
You must describe how you established the high ground water elevation:
t
l Lo> u Alf) wxt
11
r
TOWN OF BARNSTABLE
fOCATION l 0 G 101 1)rik4- SEWAGE# �r
VILLAGE C-e,4 ASSESSOR'S MAP&PARCEL /�7/ -/S -�'"
INSTALLERS NAME&PHONE NO. S -C /2111,18
SEPTIC TANK CAPACITY C
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DA E: CO /lv p
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
of
ftwN am amaa R(ddm ay9od amW awowl—j 001 aryiw Rpm Oa cowl s4FMMP +9
�
30 Pml DPaMmad owl lea!SM 9-FPlq-MWA PW"Oft—a91.W WSW 8WPUd
TOWN OF BARNSTABLE
LOCATION j` 6 (1 �z� �5�/� 0�-• SEWAGE
VILLAGE -ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY C V o a
LEACHING FACILITY: (type) l��L (size) C ��--
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by uJ:%r. "Jr �1�3 �0 2
9h Lh go
/�— /S2
TROY WILLIAMS L y
1
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection -
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS OCT 3 2002
EXECUTIVE. OFFICE OF ENVIRONMENTAL AF M i'IVEO_
DEPARTMENT OF ENVIRONMENTAL PROTECTION
OCT 7 2002
TI FLE 5 TOWN OF BARNSTABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSES ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION `L���
PropertN Address: 160 Glen Eagle Drive
Centerville, MA
Owner's Name: Dr. Edward&Corrine Prunier
Owner's Addres,: 94 Charleton Road
Dudley,MA'01571 O
Date of Inspection: September 30,2002
Name of Inspector: Troy M. Williams
O
Company Name:, Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The s%oem-
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authont)
Fails
Inspector's Signature: ::::::,:S:::,�,., Date: .2 30 /o i
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Envlronmental Protection,certificatlon Is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
F` time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
4
r` Title 5 Inspection Form 6/15/2000 pace I
f
Page 2ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr.Edward&Corrine Prunier
September 30,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 Cf\1R
1 5.303 or in 310 CMR 1 5.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be r laced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board o ealth, will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following statements. I 'not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whe er metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is i ►nent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by t oard of I iealth.
•A metal septic tank will pass inspection if it is structurally sound,n 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 igh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or ven distribution box.System will pass inspection if(with
approval of Board of Health):
broke pipe(s)are replaced
ob ction is removed
tstribution box is leveled or replaced
ND explain:
The system re ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if th approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of IgsPectiou: Dr.Edward&Corrine Prunier
September 30,2002
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.
I. S)-stem N%ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) hat the
system is not functioning in a manner which will protect public health,safety and the envir ment:
— 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 mar
2. System will fail unless the Board of Health(and Public Water pplier,if any)determines that the
system is functioning in a manner that protects the public healt safety and environment:
_ The system has a septic tank and soil absorption sys (SAS)and the SAS is within 100 feet of a
surface water supple or tributary to a surface water s ly.
— The system has a septic tank and SAS an to SAS is within a Zone I of a public water supply.
The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tan - nd SAS and the SAS is less than 100 feet but 50 feet or more frortt a
private water supply well'•. et hod used to determine distance
"This system passes ' e well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crite ' are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 Glen Eagle Drive
Centerville,MA
Owner: Dr. Edward&Corrine Prunier
Date of Inspection: September 30,2002
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
Ni,q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Nam. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
_Z Required pumping more than 4 times in the last NOT year due to c
Y � logged or obstructed ptpe(s).Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. .
N!A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. ,
Nia Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
rtA 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.]
Al O (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a sign 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 crit to above)
yes no
the system is within 400 feet of a surface drinki water supply
the system is within 200 feet of a tribu o a surface drinking water supply
the system is located in a nitrogen sitive area(interim Wellhead Protection Area—1WPA)or a mapped
Zone 11 of a public water suppl ell
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the jar system has failed.The owner of operator of any large system considered a
significant tj�fgt under Secti E or failed under Section D sh�i4 gpgrade the system in accord with 310 CMR
15.304.The system owne ou)d contact the appropriate regiottgj office of the Department. $`
4 's.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr. Edward&Corrine Prunier
September 30,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine
Yes No
_ f._;:,1 ing information was provided by the owner.occupant,or Board of I ieahl,
__. 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?
Allq Were as built plans of the system obtained and examined?(If they were not available note as N/A)
-Z _ Was the facility or dwelling inspected for signs of sewage back up? '
_ Was the site inspected for signs of break out
Z. Were all system components,excluding the SAS, located on site
Z _ 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:
Yes no
Existing information. For example,a plan at the Board of Health.
— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)13 10 CMR 15.302(3)(b)]
5 +.
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of inspection: Dr. Edward&Corrine Prunier
September 30,Zt1U®W CONDITIONS
RESIDENTIAL
Number of bedrooms(design): -3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 0
Number of current residents: O -A
Does residence have a garbage grinder(yes or no): ,vo
Is laundn on a scharate sewage system (yes or no):wo [if yes separate inspection required]
Laundry system inspected(yes or no): wlA
Seasonal use:(yes or no):_YES
Water meter readings, if available(last 2 yearsltsage(gpd)): o i = 6,ovdT s oo = Z,o�� y k /ors
Sump pump(yes or no): .vo
Last date of occupancy: O��u� y�y t s + �. s
COMM ERCIAL/INDUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): _ ___gpd
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 s or no):_
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: R,,.j 7 3e /o 2 �/.27/y_�/ 1 L�C�/yV� %/SG� p�� h,�,r• , ��.�.
Was system pumped as pan of the inspection(yes or no): /✓o
If yes, volume pumped: gallons-- How was quantity pumped determined'?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, ex,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 age of all components. date installed(if known)and sourceof information:
-,G1 < i h- 1 -6 kor , . It Gk,.e wk IIf 7 7
Were sewage odors detected when arriving at the site(yes or no):&JL
69K~
Ij4 -
f
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr.Edward&Corrine Prunier
September 30,2002
BUILDING SEWER(locate on site plan)
Depth belu%� grade: /811+
Materials of construction: ,/cast iron _40 PVC ✓other(explain): Ev
Divancr fron-, pn�ate water supply well or suction line: ,v/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
flu S f!.�a( I a.,d r�C.—A C.� d.+ �. 4i
LIJ SL �'O L.l .v� th.<� wl�%(�� n<o. co...Ka ✓'a J'f" row 7ti � ,�
rJusi.bt— c(e,5'.�.� os` I%tic M fti�virc . L;.< w—> Sha•Gcc<f o� �w1� ✓r��,. .i�
SEPTIC TANK:,�(locate on site plan)
Depth below grade: I
Material of construction:_Zconcrete_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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baftle: 2'&
Scum thickness: v o/,i�
Distance from top of scum to top of outlet tee or baftle: �—a,.,
Distance from bottom of scum to bottom of outlet tee or baffle:
Ilow were dimensions determined: e ob4.Comments(on pumping recommendations, inlet and outlet tee or baffle condition_, structural integrity, liquid levels
as_related to outlet invert,evidence of leakage,etc.):
as
o Ito.t1c< a — o A c.. rw-.t w•.K�_.. i�..� �d A. ,./
�o✓w.p%..� �¢ iIs 7S'o.rc
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_poly ylene_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 baffle:
Date of last pumping:
Comments(on pumping recommendations,inl d outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leaka ,etc.):
y 7 a
Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr. Edward&Corrine Prunier
September 30,2002
TIGHT or HOLDING TANK: (tank must be pumpe;attime of in ection)(locate on site plan)
Depth below grade:Material of construction: concrete metal fiber _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo": _ gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm and at switches,etc.):
DISTRIBUTION BOX:AI-g (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 carrygver, any evidence of
leakage into or out of box,etc.): /
.S,,wtt...t (... -f-u 1�uvL.. I' r w• '� .� c/—IC 1 7'Z•��.�I .�sv 3 s.... 7L
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition pumps and appurtenances,etc.):
8 s
Page 9 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr.Edward&Corrine Prunier
September 30,2002
SOIL ABSORPTION SYSTEM(SAS):'
(locate on site plan,excavation not required)
If SAS not located explain why
Type
leaching pits. number: I- G'x6' L to,,r ;,� / ' Sfo 4—,
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,dondition of vegetation,
etc.):
SC-H / ua c-K JJ'lnf c✓ ✓� / t.Jc.3 -e �o c✓ /h b
+.t - w i ''l__�n p_ L✓: t.Q.c.n _�:a—�` c.Qra �C✓✓.�
`� W✓Y J'C. N jr COI.ut.-f-j off S C/C /cc.-'�'i ''IS � I�.�a."} `�Y'
�ESSPOOLS: (cesspool must be pumped as part of inspection)( cate on site plan)
o'prs� v. �8yrs o I A ,
Number and configuration: __
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum la.er. _
Dimensions of cesspool:
Materials of construction: _
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of aulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction: Zailure,
Dimensions:
Depth of solids:m
Coments(note condition of soil,signs of hydraevel of ponding,condition of vegetation,etc.):
9 t'.
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Glen Eagle Drive
Centerville,MA
Owner: Dr.Edward&Corrine Prunier
Date of Inspection: September 30,2002
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.
' p r�►c �
I yd-
i
19 i I yg,
3y'
JuuuYr„{toLn
1R
Page 11 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
160 Glen Eagle Drive
Owner: Centerville,MA
Date of Inspection: Dr.Edward&Corrine Prunier
September 30,2002
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 3 y feet Adjusted high ground water elevation feet
Please indicate(check)all methods used to determine the high gruund eater elevatiow
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Hcalth-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: -5— t— 1 o ,,_ _SV W 2 s z ion„ L y j i
You must)describe flow you established the high ground water elevation:
�/✓ C, S----G vu.�,,,✓C v c..-/---cam ✓ CS�,.-
�� _..._ ..__ _ H�� b1d—..I. usJ_S ,_.ot _ �.. .'/_._e (e✓e.-.�`o,�
set I
✓o .'-.A .f["t''"^� wC.-cam w'j+'• ... u
0 0
c 0
O o U
u "
Thi
s s report has been prepared and the system inspected as of the date of inspection. This report is not a
P
warranty or guarantee that the system will function properly In the future. There have been no warranties or
guarantees,either expressed,written or Implied,relating to the system,the inspection and/or this report.
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