HomeMy WebLinkAbout0052 HUCKINS NECK ROAD - Health 52 HUCKINS NECK ROAD, CENTERVILLE
A-252-161
e
IN ® 3
UPC 17634
No.2r163`COR '�s►�, '
HASTINGS,MN
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No. Fee _�—
THE COMMONWEAL% OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplitation for Miopont 6pgtem Construction Permit
Application for a Permit to Construct( )Repair(t )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. leav Owner's Name,Address and Tel.No.
Assessor's Map/Parcel r
�wleey///e
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
6B'/`/OL9�1 G'O/167"
7
Type of Building:
Dwelling No.of Bedrooms `� Lot Size sq.ft. Garbage Grinder(11�0
Other Type of Building fe,! ) 4M.1-& No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Ile gallons per day. Calculated daily flow 33� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. y �Q,4'i I7_e/'S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
t
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Bo d f Health.
Signed Date Ap
Application Approved by Date 142—
Application Disapproved for tw following reasons
Permit No. g — 60 -6 Date Issued
--- -- ------- --------------- _-- J
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_ No:" C�C� w .z '� "�' Fee ' .�
_;.a..
THE COMMONWEAL OF MASSACHUSETTS Entered in computer:
t Yes a
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Rpoftcattol for 30t5pogar *pztem Congtructton Vermtt b
Application for a Permit to Construct( . )Repair( l<Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. C-7 �ljl�s�eell, Owner's Name,Address and Tel.No.
� G F—
Assessor's Map/Parcel ce#1iofv111e u�G
Z /� `'`��
Installer's Name,Address,and Tel.No. /C• / l Designer's Name,Address and Tel.No.
-7 Z_
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(/Zf l
Other Type of Building feJ)z0�1e'eKe No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow j gallons per day. Calculated daily flow 333 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b�his Board af Health. /
Signed ar Date /� Z /
Application Approved by ' ' Date e/GLa ?j- �
Application Disapproved fort following reasons'
s;
Permit No. — GAD -6 Date Issued fir,
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
�e�ttf ;cafe;o'f��orr��Ytance'�c�
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( Upgraded( )
Abandoned( )by 'e LD / 5 t
at '5 Z" _ Il PC has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7_ 6e5 Sa' dated
Installer Designer
The issuance of this permit s all not be construed as a guarantee that the system will function as designed.
Date ! Inspector
-----/-------------------------_------�—^--
No. — �Ga Z �_4/ Fee �1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mtgogar *potem Congtructton 30ermtt
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at 5-2 h4me /i95
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: 1 D !�?, — ��7 Approved by .1�
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10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
, hereby'certify that the application for disposal works
construction permit signed by me dated IP17.31 , concerning the
property located at �Z/���!!S /�zoG,�% �o� meets all of the
:fo711,,wing criteria:
here are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
d facility will be located within 250 feet of any wetlands,the bottom of the
• If the proposed leaching y
proposed leaching facility will a9l be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 3 7
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED:-- \ � ' , DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
TOWN OF BARNSTABLE J"
LOCATION SEWAGE #
VILLAGE f t��yZZ°�y� ASSESSOR'S MAP& LOT 2.5-Z/dr
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 0 0 (�
LEACHING FACELI TY:_(type) ,=Zirs - (size)
NO.OF BEDROOMS 3 t
BUILDER OR�
PERMITDATE: l®_Z COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) /U Feet
Edge of Wetland and Leaching Facility(If any wetlands exist A
within 300 feet of leaching facility) Feet
Furnished by
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US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for Intemattonal Mail See reverse
Sent to
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Street& u er
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P Offt State,&ZIP Code
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'Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
to
rn Return Receipt Showing to Z.
Whom--&-Date Delivered
(*.Retu446ceipt Showing to Whom,
Q Aa'f AddiesseesAddress
IWI
LL 0 T T 6 Postage&Fees $
? Post arkor Date
CL
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post.office service
window or hand it to your rural carrier(no extra charge). m
2. If you do not want this receipt postmarked,stick the gummed stub to the right of,th.o a�
return address of the article,date,detach,and retain the receipt,and mail the article. c
LO
3. If you want a return receipt,write the candied mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article` n
RETURN RECEIPT REQUESTED adjacent to the number. J a
4. If you want delivery restricted to the addressee, or to an authorized agent of the C
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the from of this-
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. to'
6. Save this receipt and present it if you make an inquiry. a
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P I11 010 325
US Postal Service '
Receipt for Certified Mail
No Insurance CoverageTrovided.
Do not use for International Mail See reverse
Xt
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Po Office State,4_ZIP Code
co<�le
Postage $ 3
` Certified Fee
Special Delivery Fee
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Restricted Delivery Fee
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Retum Receipt Showing to
Whom&Date Delivered
a Retuf"Receipt`$h wing-to Whom,
Q edake;`B.AddresseOAddiess
CO111 T AL ^ge&F8g t $
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Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1.If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the )
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends it space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. I Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the Cr
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ro
6. Save this receipt and present it if you make an inquiry. d
i
P 1.11 010 326
US Postal Service '
Receipt for Certified Mail
No Insurance Coverage'Provided.
Do not use for International Mail See reverse
Sent
f
Street&Num�r .
le CO
P Office,State,&ZIP ode
Postage $
Cerfified Fee
Special Delivery Fee
Restricted Delivery Fee
Return Receipt Showing to.
Whom&Date=Relive(ed
Q Return-Receit Shown'§W W11om,
Q fYatrt�Ad dd(ess ,�i
O TOfA P e$Fees
_ . X,, d p$
CO) Postmark or DdtiTLL
U)
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1.If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address &
on a return receipt card,Form 3811,and attach it to the front of the article by means$f the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article _ 'a
RETURN RECEIPT REQUESTED adjacent to the number. t Q
4. If you want delivery restricted to the addressee, or to an authorized agent oflthe C
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti
6. Save this receipt and present it if you make an inquiry. a
NO.
Qn DATE
fdMNBlAell d FEE '
MA88
Eo �, Town of Barnstable S EPJIBA
Board of Health367 Main Street, Hyannis MA 02601
Susan 0.Rask,R.S.
ofte: 508-790-6265 Brian R.oredy,R.S.
FAX: 508-775-3344 Ralph A.Murphy,M.D.
VARIANCE REQUEST FOR1Vi
Ali variancc requcsls must be suhmitted al(cast riftccn(IS)days prior to the scheduled(bard orlieallh meeting.
NAME OF APPLICANTS 9 . �s Z�-- TEL.N0. 7 7 3
ADDRESS OF APPLICANT
NAME OF OWNER OF PROPERTY Jjj—��tLS�A�u�Z�--•
SUBDIVISION NAME DATE APPROVED �
ASSESSOR'S MAP AND PARCEL NUMBER
LOCATION OF REQUEST _t�f
SIZE OF LOT SQ.FT WETLANDS WITHIN 200 FT.NOS
VARIANCE FROM REGULATION(List Regulation)
REA
SON FOR VARIANCE(May attach if more space is needed) 7L so
I'LAN - FOUI COPIE. OF AN UST SUBMITTED CLEARLY OUTLINI G i7LS- ,
VARIANCE I -QUEST. Aaas�k7
w� ,
VARIANCE APPROVED
Susan , R.S., Chairman 6f
NOT APPROVED Brian R. Grady, R.S.
REASON FOR DISAPPROVAL Ralph A. Murphy, M.D.
\ o,.
�, q 4-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.......�a.su.V..............OF.............9E�s.r.�rdt ,.-..................................
� �rlirtt#fort for Ropaoul Works Tonotrnr#inn ramit
Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal
SyS!zn at
S� ..7a
#11 �� �Isoc lion. Address p or Lot No .f ff
..........,Ax.� ,.tC-.u,.'/. �ee.ire t.r.Alt,�.ra.....................».. ....... Am./--1 ara.7d.,JS».rel[.1 ...................»......
Owner Address
........ i��tr.: .... Ll�r................................................ .....tQxl}Fr......I.�1a .�s...rll A...........................
Installer Address
Type of Building Size Lot...LD.., �a........Sq. feet
Dwelling—No. of Bedrooms....�A.r.x.e:................Expansion Attic ( ) Garbage Grinder W0)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .........................................................................................................................................gal- n-s.
all ons
Design Flow...............................Sr S:._-.gallons per person per.day. Total daily flow......... -T.0......................
Septic Tank—Liquid capacityl,pina.gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width....................Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.../fv.+.f.'9m.i-Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
t� Percolation Test Results Performed by........................................................................ Date..........................................
Test Pit No. 1.........'�......minutes per inch Depth of Test Pit.....t'o2........... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Rt' ::.............................................................�............................................................................................
O Description of Soil....j... .... �....=..�a,ur��...►•..,5�.�5e�1.--•-�... '.T..1 .'./y1� .-s'�ir!�t ."'., sa<✓d.,
_.......................... . ...................................................
.............................................................................................................
.........................................................................................
Nature-of.Repairs.or..Alterations—Answer when applicable..............................................•........--••-••----------•--•------•••.:......•.
..................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribf-d Individual Sewage Disposal System in accordance with
the provisions of TITLI' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Irn b the thmr. of health.
Signed...,f�j,.....
Date
........................................
Application Approv By.................................................................................................. Date
Application Disapproved for the following reasons:...............................................................................................................
...................................... ..................
......:....»..........................................•---............................-_...................................... Date
..»»» Issued....=..../...'..[-rl..............._....
Permit No................................
Date
„—
{ � f -T `' r THE COMMONWEALTH OF MASSACHUSETTS
BOARD :OF HEALTH '
................OF Y:. /1 lt../.::.1. �.... ..fJ.L.......................................... ;
ha e Individual V sa System constructs or Repaired
Y ,..,-T'HI� IS TO CERTIFY T t the I dividual Sewage Dispo 1 Sys .........................................................
d (L:) - Repa: ed (» )
..._...........»........ .....................................
rr Installer y
S ............................
:;.'; ': •;;.�' at.....::.:. :..........1�7..rc.�..!f:?.� .....»�`!. .4!s.....1�...1`1.....................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
. --•••..................••........_..............
application for Disposal Works Construction Permit No��l- ?G..,l................ dlted <'
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
,, SYSTEIIA WILL,FUNCTION
SAT . F<�tta7'�R�'>
DATE.....:...... _: ..-...... ....•ram•.................... Inspector......... .............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l !....r.....,../.'•j.......OF"........ ./.J.;.L.........A..lJ. ...............................
.C.i..... .....
Diopoottl Marko Tonotrudion f rrmit
Permission is hereby granted..........:.:. :..:...............4; ....»...4.4.:.L.. ..::..::....................................................................»....
to Construct l(/) or Repair ( ) an Individual Sewage Disposal System
at No... x. .
.../.1. .:.s:.:.s�.......:..........: .......... .............. '
-street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
........................................................................ j
:............................... Board of Health
DATE................................................................................
FORM 12Sd Has 6 WARREN. INC.. PUBLISHERS ^
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TANKS] 71 FUEL STORAGE TANK RECORDS ] HELP [ ]
FOR PARCEL NBR: 3081 1431 ] ] MAIN ACTION C]
Action Tank Nbr Tag Nbr Installed Location ----Notification Dates-----
[ ] [ 11 [ 8581 [0101811 [B ] Test ] Rem ]
---- Test --- --Abandoned-- -- Removed -- -- Variance -
[3] [0305961 [ ] [ ] [ ] [ ] [ ] [ ]
Fuel Reason Capacity Constr Status Leak-Det Cath-Det
[G ] [B ] [ 100001 [FD] [N ] [Y] [ ]
Additional Details [TEST #1 5/19/94 TEST #2 0309951
--------------------------------------------------------------------------------
Action Tank Nbr Tag Nbr Installed Location ----Notification Dates-----
[ ] [ 2] [ 8591 [0101811 [B ] Test ] Rem ]
---- Test --- --Abandoned-- -- Removed -- -- Variance -
[3] [0305961 [ ] [ ] [ ] [ ] [ ] [ ]
Fuel Reason Capacity Constr Status Leak-Det Cath-Det
[G ] [B ] [ 100001 [FD] [N ] [Y] [ ]
Additional Details [TEST #1 5/1994 TEST #2 030995 ]
--------------------------------------------------------------------------------
Cancel [ ]
Press XMT for more data
NEXT SCREEN [TANKS] ACTION [C]
PARCEL NBR [308] [143] [ ] ] TANK NBR [ 31
[ ]
y t
SIX
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
rad
One winter Street,Boston,M, -.a .tole Septic
. Title V Septic htspector
/� J O. Box 2119
n ( Te icket, MA 02536
WILLIAM RWELD / �508)f5,64:68-1,3
Governor CC��
ARGEO PAUL CELLUCCI �� /?
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION J L r C c p 2 2 1997
Property Address: 52 Huckins Neck Rd.Centerville Lot 152 Address of Owner: !iJ OF BARNSTABLE
Date of Inspection:9/16/97 (If different) 1,:ALTHDEPT. Or
Name of Inspector:John Grad Espinoza r
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) f
Company Name,Address and Telephone Number: L
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This inspection is based on criteria defined in Title V
Conditionally Pa es code 310 CMR 15.303.My rmdings are of how the system is
• Need/bmit
er valuation B the Local Approving Authority performing at the time of the inspection.My inspection does
Y PP 9 tY not imply any warranty or quarantee of the longevity of the
X Fails septic system and any of its components useful life.
Inspector's Signature: ' Date: 9116/97
The System Inspector shall s copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
Indicate yes,no;or not determined(Y, N,or ND). Describe basis of determination in all instances. 'If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic lank,whether or not metal, Is cracked,structurally unsound,shows substantial Intiltialim ui exfiltiatiull,ur tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 0427197)
One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 9 Telephone(617)292-5500
r '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
_ Sewaae backup or,breakout.or, hiah.static water level obser.ved.in.the distrihution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
>(gu must indicate either"Yes"or"No"as to each of the following:
�( I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ -x— Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_X` Discharge or ponding of effluent to Ilia surface of the ground or surface walers due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16197
D] SYSTEM FAILS(continued)
Yes No
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 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— Numbers of times pumped
x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
—X Any portion of a 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.
—JC 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
x — As built plans have been obtained and examined. Note if they are not available with N/A.
X — The facility or dwelling was inspected for signs of sewage back-up.
X — The.system does not receive non-sanitary or industrial waste flow.
— The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge, depth of scum.
X _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— unacceptable)115.302(3)(b)]
(revised 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 4
Garbage grinder(yes or no): Yes
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
n/a
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
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: n/a
OTHER: (Describe) We
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was pumped two years ago.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
R Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
VA Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source information:
1990
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:X concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age a . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L B'6'H 5'7' W 4'10'
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: Measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal FRP Polyethylene_other(explain)
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 pumpingw,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 3'
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction linelo—
Diameter: 4'
(ntamments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04127/97)
ie
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_FRP_Polyethylene_other(explaln)
Dimensions: n/a
Capacity: n/a gallons
Design flow: We gallons/day
Alarm level:_n/a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
n/a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n/a
(revised 04127/97)
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 52 Huckins Neck Rd.Centerville Lot 152
Owner: Espinoza
Date of Inspection:9/16/97
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n/a
Type:
leaching pits, number: 1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries, number: n/a
leaching trenches,number, length: n/a
leaching fields, number, dimensions:n/a
overflow cesspool, number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit is past the effective depth of leaching.The sas is in hydraulic failure.Pit was full.
CESSPOOLS:_
(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: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
We
PRIVY:_
(locate on site plan)
Materials of construction: n/a Dimensions: nla
Depth of solids: We
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n/a
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
52 Huckins Neck Rd.Centerville Lot 152
Espinoza
9/16/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where.public water supply comes into house)
c
i—T eJ
AA 3c
yj
(revised 0V27/97) page 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
52 Huckins Neck Rd.Centerville Lot 152
Espinoza
9116/97
Depth of groundwater 12+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
i
(revised 04/27/97) Pago 10 of 10
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