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Home My WebLink About0100 HOLLY HILL ROAD - Health 100 Holly Hill Road Centerville. A= 188-091 SMEAD No. 2-153LOR UPC 12534 smead.com - Made in USA ��cvcr.�o 2 4 [' FW USF'U L4 W KWUQ UNE 5 f' man SFI PiEOGitMA�� SOtJR(]NG NJVVW-Vrmxwmm TOWN) OF BARRNSTABLE LOCATION (OO H Jk\/ LA t t I RC , SEWAGE#. VILLAGE C'��e.(V� , ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Ce.SS 00 LEACHING FACILITY:(type) CaSSpay (size) NO. OF BEDROOMS 1 OWNER CO W PERMIT DATE: 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 GAGA%O- Q. A � L3 ► 33 33 a- q( Sq COMMONWEALTH OF MASSACHUSETTS EXE CUTIVE OFF ICE OF ENVIRONMENTAL AFFAIRS x DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 100 Holly Hill Road Centerville M,4 026.32 Ow ner's Name: Jim Brown Owner's Address: Date of Inspection: November 16 2609 Name of Inspector: (Please Print)Janies M Ford Company Name: James M. Ford Mailing Address:.. P.O.Box 49 Osterville,MA 02655-0049 Telephone Numbers (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes. Conditionally Passes fqkeds Further Evaluation by the Local Approving Authority. I is Inspector's Signature: Date: November 18, 2009 The system inspector shall subritaopy.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 Coininents ****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 1 6 L b°� Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jinn Brown Date of Inspection: November 16, 2009 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 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 of 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 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 se system has a tic tank and SAS and the SAS is within a Zone 1 of a public water supply. Y p 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 detenmine distance "This system passes if the well water analysis,performed at.a DEP certified laboratory, for colifor m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 i Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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. 1 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 System: 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 406 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-1WPA)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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 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 infonnation 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 inforination. For example, a plan at the Board of Health. ✓ _ Detennined 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: 100 Holly Hill Road Centerville, AM Owner: Jim Brown Date of Inspection: November 16, 2009 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 -Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown 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 Source of information: Unavailable 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 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: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 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: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 10" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5'wx5'txftottoni to.&ade Sludge depth: 0„ Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: . - Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions detennined: Measuring stick 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 Cesspool had 3'of ILguid on the bottoin. The cover was 10"below grade. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM PART C SYSTEM INFORMATION(continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 TIGHT or HOLDING TANK: None (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 Alain present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Coinnents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Nome (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (dote 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: None (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 SOIL ABSORPTION SYSTEM(SAS): . ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: li leaching fields,number,dimensions: overflow cesspool,number: I -overflow 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.): The overflow Was dry and clean. The scum line was app. 6"u,2 fi-om the bottom. There did not appear to be anv suns of failure. CESSPOOLS: None (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: 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.): 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: 100 Holly Hill Road Centerville, M.A Owner: Jim Brown Date of Inspection: November 16,2009 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. GArAtk- Q 133 33 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 100 Holly Hill Road Centerville, MA Owner: Jim Brown Date of Inspection: November 16, 2009 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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: topographic and water contours snaps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approxnnately 25'+/-ground water at this site. . This report has been prepared only for'the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, ivritten or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11