HomeMy WebLinkAbout0198 HUCKINS NECK ROAD - Health 198 HUCKINS NECK RD., CENTERVILLE
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UPC 12634 '
No.2 OR
MASTINOS,YN,
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION t
o
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P14146
Name of Owner RONALD KEENAN ;
Address of Owner: 198 HUCKINS NECK RD CENTERVILLE,MA 02632 Date of Inspection: 7/31/00 � -
Name of Inspector: JOHN GRACI TOWN OFBMNSTA&Z
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) \ HEALTH DEPT.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 'f ,
Telephone Number: 508-564-6813 FAX 608-564-7270
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 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:
X Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:8/1/00
The System Inspector shall sub Wt a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life"
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7/31/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
n/a 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 tank,whether
or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system
will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n/a 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
4
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 198 HUCKINS NECK RB C€NTERVILL€, MA 02632 M261 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7/31/00
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance Wa(approximation not valid).
3) OTHER
n/a
revised 912/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7/31100
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 into facility or system component due to an 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 1/2 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 o.
- 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 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.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"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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:
s+
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 upgrade the system In accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
�t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M261 P141;
Name of Owner: RONALD KEENAN
Date of Inspection: 7/31/00
Check if the following have been done:You must indicate either"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 - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this inspection.
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.
X _ 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.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal
Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7131/00
FLOW CONDITIONS
RES113ENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:1
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COM MERC IAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: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:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1979
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7131/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 36"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
n/a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 30"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
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: n/a
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
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:
(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
revised 9/2/98 Page 7 of 1 t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7131100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION 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
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 109 NUCKINS NECK RD CENTERVILL€, MA 02632 M291 p141
Name of Owner RONALD KEENAN
Date of Inspection: 7131/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (2)15
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
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 TRENCHES APPEAR TO BE FUNCTIONING PROPERLY. THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY
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)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
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
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7/31/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 HUCKINS NECK RD CENTERVILLE, MA 02632 M251 P141
Name of Owner RONALD KEENAN
Date of Inspection: 7/31/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 8 Feet n/a
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
Checked pumping records
_ Checked local excavators,installers
_ Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
GROUNDWATER IS DETERMINED FROM TRANSIT/STORYPOLE-8+FEET,
I
revised 9/2/98 Page 11 of 11
�g v
Comm meotth of Mossochusetts ,John Grad
ExecMe Office of ErMrorrmntol Affofrs D.E.P. Title V Septic Inspector
Department of P.O. s�X 2I I9
' Environmental Protection Teaticket,MA 02536
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ^�
PART A RfCf� �
CERTIFICATION
r° ► 1 qp, 6 199?,
Property Address: 198 Huckins Neck Rd.Centerville Address of Owner:
Date of Inspection:615197 (If different) 14
Name of Inspector:John Graci Jerald Eady 3 Deepwood Dr.wilbrah 1095
Company Name,Address and Telephone Number:
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:
X Passes This Inspection is based on criteria defined in Title V
Conditionally asses code 310 CMR 15.303.My findings are of how the system is
Needs Furt r Evaluation B the Local A rovin Authori performing at the time of the Inspection.My Inspection does
Y PP 9 tY not Imply any warranty or guarantee of the longevity of the
Falls septic system and any of its components useful life.
Inspector's Signature: ' Date: 6113197
The System Inspector shall sub it a 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:
X 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.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. if "not determined", explain why not.)
The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11/15195)
One Winter Street 9 Boston,Massachusetts 02108 a FAX(617)556-1049 9 Telephone(617)292-5500
1
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 198 Hucklns Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.lAllibraham Ma.01095
Date of Inspection:615197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is 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 water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 198 Huckins Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.Wllbraham Ma.01095
Date of Inspection:615197
D] SYSTEM FAILS(continued)
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
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:
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 (IWPA)or a mapped Zone 11 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 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 198 Hucklns Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.Wilbraham Ma.01095
Date of Inspection:615197
Check if the following have been done:
X 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.
X 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 existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 198 Hucklns Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.WliUM=Ma.01095
Date of Inspection:615197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings,if available: nla
Last date of occupancy: weekends
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present:(yes or no) N0
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: Ma
Last date of occupancy: n1a
OTHER: (Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been been pumped in the last two years.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 9 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X 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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1979
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 Huckins Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.Wilbraham Ma.01095
Date of Inspection:615197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 3'
Material of construction:X concreate_metal_FRP other(explain)
Dimensions: L8'6'H5'7"INV10-
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:1'
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: 17"
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 system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n1a
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
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.)
nla
(revised 11115195)
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 Nuckins Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.Wilbraham Ma.01095
Date of Inspection:615197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: n1a
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rVa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
D-box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
(revised 11115195)
7
'J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 198 Hucklns Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.Nfllbraham Ma.01095
Date of Inspection:815197
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:
n1a
Type:
leaching pits,number: n1a
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number,length: 2'15'trenchs
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Sas is functioning properly.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
Na
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
nla
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n►a
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
Na
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 199 Huckins Neck Rd.Centerville
Owner: Jerald Eady 3 Deepwood Dr.UVllbraham Ma.01095
Date of Inspection:615197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Do6
C
I'
A
A
4q
rc lit
DEPTH TO GROUNDWATER
Depth to groundwater:8 feet
method of determination or approximation:
Transit and Storypole
(revised 11115195)
9
No.._.................. ................
THE COMMONWEALTH OF MASSACHUSETTS susjl C, TO
APPROVI
BOA
RD" O F HEALTH IRNOTAKE CONSERVATIO14
Town...................OF...........Barnstable. CMMISSION
Appliratiun for Uhip ual Works Towitrnrtiun ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
Huckins Neck Road Centerville Lot 1%
.................. -• --•-•-......-•----...._... -----.._._.._..._........------------...............-•---...----•-•-•---..._.............
Location-Address or Lot No.
_Clarence . Larson 40 French,St. Not_,Qiiincy�
--------------•- --••----.. . --------
ner -----------------------------•--Address
Installer Address
d Type of Building Size Lot...
...... 4......._._Sq. f^ryet
U Dwelling—No. of Bedrooms...............3...........................Expansion Attic ( ) Garbage Grinder (aQ�
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................... ..
W Design Flow.................................... ......gallons per person per day. Total daily flow..........33'P...........................gallons.
WSeptic Tank—Liquid capacity.l0�O.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..........2........\Width........2. ........ Total Length.......:15._...... Total leaching area......1QQ-......sq. ft.
Seepage Pit No..................... Diameter.-_:, ._......... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X ) Dosing tank1-4
( )
Percolation Test Re u is Performed by........RichardFairbatzkt_...E Date....June. 139---1279.-
2 .....minutes per inch Depth of Test Pit..12............ Depth to ground water..... -•. .
� ,• Test Pit No. 1 _...... S �±...__.
(s, Test Pit No. 2..".aP9L..--minutes per inch Depth of Test Pit.................... Depth to ground water........................
------ ------------------ ------------------------------------------------------------------- .............•........
...
0 Description of Soil...........0-12.. - ;oa-m atld TO�s-- 0�.1____.._12-14411! Medium sand atld gravel
x
w
x -•••-----•---•----------------- --------••-------•--------•....__....------••....•--•--------........---•------•-------------•-----------------•----•-•---•.--••---•--------•-----••------..............
i
U Nature 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 T!TIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has issued,b�ypthe board of health.
Signed = =' ------- ............... ..., ..... •--
Date
ApplicationApproved By...r....-....................................................................................... ........................................
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------•-_...
..................................................................................................................................•-•--------•---•-•-••••-----••--•------••-------•-•-----••------..•--•-
Date
7
Permit No............ Issued ............-- ---.. ------
Date
J
1
No.._.. ....._.':... Fxs...r �
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town...................OF.......... .....tab .Q.
Appliration for Bi.spusal Works Ton#rurtion ermi#
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
"'----_ System at:
1a� Neck Road Centerville Lot 146
................ ................... ........... .. .......
Location-Address or Lot No
C nce Tsezx 4_0.Fi'exich•St. NQ•... ':..1" .(?2't
......................__.,_...._..... .. ......................................... .. ..--
ner Address
W 1_ _
a ._......... .....................'.._._..................._.
�i Installer Address
Type of Building Size Lot__t�.�5Oc?. _..Sq. f t
aDwelling—No. of Bedrooms..............3...........................Expansion Attic ( ) Garbage Grinder
Other y.Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04
Other fixtures ....... ------------------
-•---------•-
W Design Flow............................................gallons per person per day. Total daily flow..........339......_.....___.__......gallons.
GG Septic Tank—Liquid ca.pacit .� O.gallons Length.......:........ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width........ !..._.... Total Length.......151...... Total leaching area......1 .......sq. ft..
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (,X ) Dosing tank ( )
11.4 Percolation Test Re u is Performed by._.....4� �� +�J�.................. Date....iN4l .b..M2_
04 Test Pit No. 1 ._,: _ ..__.minutes per inch Depth of Test Pit_1 9............ Depth to ground water.....g+4._:L.....
44 lest'Pit No. 2.�; ....minutesper inch Depth of Test Pit.................... Depth to ground water........................
w z'
D Description of Soil.......... '" 2't QM axid TOPSO . , 12�+11 rt M@t ttln � 7t 1c3 g Ve .
-------------•------ -._...• -------- ....---- -- ----------------------•----------._.....------...............__---•-•----••......
W ._-- -t ----• •..................... .....-------------•--•----•-•-•-----•------------...------------••---•---------------------------•--•-------------.......---•-•....._........----
x .............----------=--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of`Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
.................
--------------.;,
-----------------------------------••-------....------------......-------------------....----
Agl eme`nt
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with',
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has k e issued byf the board of health.
. _. f/df}6J r e
Si ned -- _..al"' . - i• ... ..g .�_...... R° I �% i/w Date
Application .Approved By.... ........-------------••-•-----........_...-•-----...---•------....._•----••-•-----__----•- --•-•--------------------------•--------
Date
Application 4Disapproved'for the following reasons:.................................................................................................................
w •.............•------------•---=--•-•-----••-•--•-----'----------••-.....---------•----...._..---•-...-----•-------------••--------------••••---------------•--------•--------•-----------------•••_-----
• Date
;. Permit No.....................--••------•------------------------- Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -19THEALTH
..........I. z !. ............OF........ C� .:..................
Trdif iratr of Toutpliunrle
THIS TO RJFThat the Individual Sewage Disposal System constructed ( r Repairedby �r s -. _ .. ..... . •--- --
alY #
___at__..... �•.has been installed in accordance with the provisions of T _ 5 of The State f Sanitary C e, as described in the
application for Disposal Works Construction Permit No .. -----_. dated------ ---•---..-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................•••--•--•-•-•--•-••_.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
... '..........:......OF.......... ....
Rf �1.
No._......����� .....•. FEE...t
Uiuposat rk tr iurt " rmit
.' .;
Permission is hereby granted--.--- ---------- ------- . ----------------......................... -.. .....................
.....................
to Constr or`R pa' ( ) jndivid Sever D o S t
._.. �--
at No.. �.,. 1 . �j
' Stree�"" "
as shown on the application for Disposal Works Construction it Dated_ .4?'' ,P............
4A
.............
X Board of Hea
DATE.... ..._- Il!�*ry�' r
FORM 1255 HOBBS & WARREN, INC., PUBLISHERSr.,,.d " '
U� )
LO TION � � f EWAGE PERMIT NO.
ea
VILLAGE
INSTALLER'S JNM E i ADDRESS
J
OR OWNER
OV
DOE PERMIT ISSUED `l '� /
DATE COMPLIANCE ISSUED
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