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Centerville
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION "}`
•
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 68 Halyard Way
Centerville MA 02632
Owner's Name: John Harrington
Owner's Address: Same �Z J//
Date of Inspection: September 3,2005 Job#05-271 7'
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 systepts. I am a D
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ��H F
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority c :M
Fai ELL ;co
Inspector's Signature: m Date: 9/3/05 %, RTtF1 'oQ'�•�`�
iNSPE��
JUM
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heat 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: High stain lines in leaching pit indicate 8"of effective leaching.Tank is not in need of
pumping at this time.
****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 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I 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 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, 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:
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:
Title C Incnartinn Rnrm rli snnnn 2
i
(p Page 3 of 11
U' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
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
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 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:
Titla G inenantinn i7t% m 4/1;nnnn 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: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X_ 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.]
_No_(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 design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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.
Title C incns.ntinn 17^r 411 ciInnn 4
Page 5 of 11
Lf
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
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?
_X_ 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 components,excluding 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
_X_ Existing information.For example,a plan at the 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)]
Title c i--t;—i7^—4/1 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003—127,000 gal.2004—129,000 gal.=350 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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: Tank pumped 4 years ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
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
_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 source of information:
1984
Were sewage odors detected when arriving at the site(yes or no): No
Title i Tncnpr6nn i7nrm 4/1 i/inAA 6
ij Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: 30'
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 6"
Material of construction:_X_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:8.5' long x 5.2' wide—1000 gal.
Sludge depth: V
Distance from top of sludge to bottom of outlet tee or baffle: 29"
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: 12"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles intact and clear,liquid level at bottom of outlet invert.Tank is not in need of pumping at this time.
GREASE TRAP: No (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.):
Title 4 lnenonfinn P^'—Ail zmnnn 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: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
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:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
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.):
No solids or high stains,liquid level at bottom of single outlet aiae
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
T41a G Incnontinn P^r 4/1 ci,)nnn 8
' Page 9 of I 1
1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
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.): Liquid level currently 16-18" below inlet pipe,high stain lines indicate 8"of effective leaching.
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.):
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.):
TIt1P C incnnntinn P^r 411�;i)nnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.
Halyard Way
Driveway Water service
# 68
Garage
Porch
27
36 5
11 12
29
Titla i invnarfinn Anr ul;i)nnn 10
1
j, • Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 Halyard Way,Centerville
Owner: John Harrington
Date of Inspection: September 3,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 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)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.35 and topo map shows property at el.90.
T41a C incnaMinn 17nrm All ai)nnn I I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner's Name: MR GREENE
Owner's Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Date of Inspection: 6/28/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furt 1"'10
aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 6/28/01
The system inspector shall submit a co of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. i 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
SYSTEM PASSES TITLE V INSPECTION. RECOMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
****This report only describes conditions at the time of inspeetiun slid under the conditions of use at that tiute.'flits
inspection does not address how the system will perform in the future under the same or different conditions of use.
.Title 5 Incnertinn Fnrm 6/15/)(100 I
Page 2 of 1 I .
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I 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 PASSES TITLE V INSPECTION. RECOMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
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.
Answer yes,no or not detenmined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or breakout 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
NU e kiN: i0ii
Page 3 of I 1
a
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE, MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
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(I)(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
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 n/a
"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:
n/a
s
z
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 forma
(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 detennine 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.
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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 oper0tor of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 68 HALYARD WAY CENTERVILLE, MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
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 ?
X 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 components,excluding 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
X _ Existing information. For example,a plan at the 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 I I `
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COM MERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CM 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components, date installed(if known)and source of information:
16 YEAM
Were sewage odors detected when arriving at the site(yes or no): NO
• Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE, MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
n/a
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 4"
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: 14"
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.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/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: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working,order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY-.NEVER MORE THAN HALF FULL-NOW IT
HAS ONE FOOT IN PIT
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
a
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE, MA 02632
Owner: MR GREENE
Date of Inspection: n/a
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.
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Page 1 1 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 68 HALYARD WAY CENTERVILLE,MA 02632
Owner: MR GREENE
Date of Inspection: 6/28/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+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: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
11
{{ �j TOWN OF"BARNSTABLE
1 0CAnON 6U 6y��✓�`��i ��S/ SEWAGE #FA sW y
VILLAGE &&ftr villa ASSESSOR'S MAP & LOT /g-V
iNSTALLER'S NAME&PHONE NO7-��r'llck C:.ev►rj 28- 1.7 79
SEPTIC TANK CAPACITY '/OCR
LEACHING FACILITY: (type),�)'r (size) /60
NO. OF BEDROOMS
BUILDEROR(Z� he) 966friAg7dn
PERMITDATE: COMPLIANCE DATE: 3
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
r
ZG
Z9
Board of Health
Town of Barnstable
P.O.Box 534
No... 5.�6 _ Hyannis,Massachusetts 02601 Fes$................®.,®e
N 4- -A3 THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
....oF.... A0
t
U.........................
J
,� lirtt#iilan fnriutt1 larks C� x> r#iun r i# �yZ
ication is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewa isposal
st t:
. _..... ... ...�. ...... ............ � .
... .-
ation• dress — N
...... ................•..............
o'W Addr ss
a ...................... --•-••--•-• - ...................................
Installer Address y �� /�
Type of Building Size Lo /.___.J____.___._`/'�--...Sq. feet
U Dwelling—No. of Bedrooms............ ...........................Expansion Attic (OU4 Garbage Grinder Woo
a`4 Other—T e of Building No. of persons............................ Showers
YP g -----.-.•--...-•--------...- P ( ) — Cafeteria ( )
d Other fixtures
W Design Flow........._/.o__________ _ gallons per person per day. Total daily flow-------------.s.� ...._.....----------------.._.._.._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 nk
Percolation Test Results Performed by. ....__..._ . Date......
W
Test Pit No. I................minutes per inch Depth of TestDepth to ground water.._....______._.__.__...
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P' --- ---•-----...
ODescription of Soil Q.-. ...... G'c .�--. --•----------••••-••-•••......•--•-
x -
V - G� 4..� --------
W
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
. --••••---•-•••••••-•••-•-••••--•-•...............•--••.....•••-••-••-••--••--••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of,'LET,LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
oper n ' til a ertificate of Compliance has been issued by the board of 1 alth.
Signed••-• -----.•••-... /..1 d�.��
Date
Application Approved �Y 11. .D
Date
Application Disapproved for th following reasons:---•---------•••••-•----•------•----• ---------•-•-•--•-----••---••---•••-----•-•-••••......--•-••••...--•---
---•••••-•••••-•-••••-•••••-•••-•--•••••••••.............••••...-•-••••••-••.....••-------•-••-•••••--•-•••-•••••....._....•-•-••••••-••••••••-••••--_.....•••••-••-•---••----••----•-••--•••-.......---
. Date
?I. ..Permit No........5 -......................... Issued.....-1_�`..�-I=R- - -•.- ------
No.75 CL .............................
144 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF `HEALTH
.......................
...................... ... ........
pliftratit-it for 11ispasal Marks Tonstrurtion Frrutit
Application is hereby made for a Permit to Construct (�or Repair an Individual Sewage Disposal
System,at:
...... ... ........����... ......--------------------f--------- ------------ -- ------ ----------------------------------------------------------------
,Location;' dress f Owner........... ..................... .............&�__ ...................................
.
ddress
..... . ......... .... .. ...... .......................... ........... ti✓ ................................
Installer Address
U
Type of Building Size
Lq ...4...
. ..... ....Sq. feet
Dwelling—No. of Bedrooms._.._._... ............................Expansion Attic WJ) Garbage Grinder
aCafeOther—Type of Building ..............................No. of persons............................ Showers
teria
OtheTfixtures ......................................................................................................................................................
Design Flow.......Yl.a..........................gallons per person per day. Total daily flow........._53a.....................gallons.
9 Septic Tank—Liquid'capacity............gallons Length................ Width.._............. Diameter-_______-___--.- Depth................
Disposal Trench—No..................... Width............._...... Total Length.__....._....._..... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.........___.__..... Depth below inlet............._._.... Total leaching area..................sq. f t.
z Other Distribution box Dosing nk
"j
Percolation Test Results Performed by. KIZ�i_/.............. .•... ..2.................. Date....../--
.Z.� 7- � -/.--7 ----
Test Pit No. 1................minutes per inch Depth of Test Pit----- ............. Depth to ground water..._.............._.....
(X4 Test Pit No. 2................minutes per inch Depth of Test Pit.___................ Depth to ground water........................
9 -----------------------------------......_:�.... --- ----------------
.........
0 Description of Soil...., ...*--------"----------"-----------------"-------------------
-.......
-- ------ .......Z................*
.. -------------*----------------------*---------------------------
---------- . ............................................................
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
'I'LL the A6vi is 6 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
AlQN,
0 iQ u I rtificate of Compliance has been issued by the board of health.
Signed--..r%11�_i,:F_f._i'....7_�...... .............
t ;.. 1
ApplicationApproved By.............. --------------------- ----------------------------------------
'6v Date
Application Disapproved for the f wing reasons:....................• ...............................---------------------------------------------------
................................................................................................................... ----------- 7----------------------------------------- --------
ate
Permit No.............ez?s;.....C5-------------------- IssuedL........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD`:'OF HEALTH
........................::tom-7t ........OF...... .............. ......................
(9prtifitate..of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed )( or Repaired
by......... ...... ....... ......................................................................................................................
at...... .,` ...../Z
,;Z,��, / ...................................
has been installed in accordanc t the provsi
E!� ihh i
w onsof TITEE 5 of The State Sanitary Code as described in the
application for Disposal Works.Construction Permit No......................................... dated__..._.___...........___________............_...
MC
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO. TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
— .7 .......... Inspector.........DATE........... ...... .0 -.0 .................THE A
� .... .....................
COMMONWEALTH OF MASSACHUSETTS
I
BOARD I OF HEALTH
_1V
.........................:��........OF..../ ���..........14..............................................
FEE.........................
Permissionis hereby granted..............................................................................................................................................
to Construct ( 'ror Repair an Individual Sewage Disposal,System
at ...M/ zzl-��lz....... ----------... . ......... ......... ........................................
Street
as shown on the application for "osal Works Constr/1;c2tion Permit No............... . ........1-c',64e F,-,-
(7 ARIU11 .2).
0 W.- .......................................... ...y..................................................
DATE................................................................................ Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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