HomeMy WebLinkAbout0083 KATHERINE ROAD - Health 83 KATHERINE RD., CENTERVILLE
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Irk DATE: 814199_____
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PROPERTY ADDRESS:—83 - Katherine Road
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Centerville ,Mass .
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02632
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Z Z V0 Z
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 2-6 ' x8 ' block cesspools .
Based on my inspection, I certify the following conditions:
2 . This is not a titlt five septic system.
3 . This is a sewage system. The sewage system is in proper workig
order at the present time .
4 . Pumped main cesspool at time of inspection .
5 . Water intrusion did not take place .
SIGNATURE:f
Name:_,L, P_ Macomber _jj ______ 9-
Company: Jose_2h_P. Macomber—& Son , Inc .
Address:_ Box—66------------- �f' via 1
A(lc 2 !
Centerville , Ma . 02632-0066 3 19n
-------------------- TDoF
Phone: 508_775_3338_______
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
(JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
c 5.3338 775-6412
COMMONWEALTH OF MASS4CHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500
TRUDY COX
Secrete
ARCEO PAUL CELLUCCI DAVID B. STRVI-
Governor Corr:.:ss:oa
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:Harold D. Dick NwTwofowrw Harold D. Dick
83 Katherine Road Centerville Addrassofownar:
Data of Inspection:
Name of Inspector:(Please Print) Joseph P. Macomber Jr.
I am a DEP approved system Inspector pursuant to Section 15.340 of Thds 6(310 CMR 15.000)
cc-m ny Nam.: Joseph P. Macomber & Son, Inc.
MbIN Address: 2632-0066
Telephone Number: 5 0 R-_ _ 3 3 3
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 cn my training and experience In the proper function and
maintenance of on•site sewage disposal systems. The system:
asses '1
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
trtspactW's Signature: Dater
The System Inspect shall submit 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
Mail submit the report to the appropriate regional office of the Department ot,Environmenzal Protection. The original should De s ant to ma
system owner•and copies sent to the buyer.If applicable, and the approving authority.
NOTES AND COMMENTS
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revised 9/2/98 Page 10(11
C, Ymtad on Recycled Vapor
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirwed)
PropertyAddress: 83 Katherine Road Centerville ,Mass .
Owrw: Harold Dick
Date of Inxpection:8/4/9 9
INSPECTION SUMMARY: Chuck A, A C, or D:
A. SYSTEM PASSES:
CEid, 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.
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.
Indicate yes,no, or not determined(Y. N, or NO). 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 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.
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(:) are replaced
obstruction Is removed
distribution box Is levelled or replaced
The system required pumphtg-more than'fourtimes-a-year-due to broken or obstructed pipe(s). The o•MWM WHI-pasr
Inspection if(with approval of the Board of Health): -
broken pipe(&) are'replaced
obstruction is removed
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPtCTION FORM
PART A
CERTIFICATION (continued)
PropertyAddre": 83 Katherine Road. Centerville ,Mass .
Owner: Harold D. Dick
Data of Inspection: 8/4/9 9
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.WtLL.PRQTECT THE PUBLIC HEALTIJAND SAFETY ARID THE B"MONMENT:
4 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:
A 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 pre,/s�ce of-ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance j'l (approximation not valid).-
3) OTHER
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SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPeCTiON FORM
PART A t_
CERTIFICATION (continued)
NopertyAddress: 83 Katherine Road Centerville ,Mass .
Owner: Harold D. Dick
Date of inspection: 8/4/9 9
D. SYSTEM FAILS:
You ust 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
Backup of"Wage imoiecilityrorrfstem component duerio an overloaded orciegged-SAS-Of-ICOS3POO1. --�"
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 istribution bo bove 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 th 4 times In the last year NOT due to clogged or obstructed pipe(s).
Number 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.
4-1 Any portion of a cesspool or privy is-within a Zone I of a public well.
Any portion of a cesspool or privy is within So 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:
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:
Yes No
the system is within 400 feet of a surface drinking water supply
the system•is-witl4n 200 feet of-a-tributery-(oa wrfao"#4ik44,,9 vwater•4upply —
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 15.304(2)• Please consult the local regional
office of the Department for further Infor nation.
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revised 9/2/98 Page 4ofII
1
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B '
CHECKLIST
PropertyAddress:83 Katherine Road Ceriterville ,Mass .
Owner: Harold D. Dick
Date of Inspection: 8/4/9 9
Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following:
Yes No
1/ Pumping information was provided by the owner, occupant, or Board of Health.
None of the system•compownts.kamaJisen puatped4orzatJsast•t+ oawaaks swdtbe rystem hasbaaoascoiaipg+w�al flow
rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they ar not available ith N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components,-eexcluding the Soil Absorption System1have been located on the site.
..j
_�it1OA The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or Was, matirial of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b))
_ The facility owner.(and.ocr,-pants..)f different fr=.owcner)..wwa prcuided.with lnfnrmatioaDn tha unpat ntaaaac ^f
SubSurface Disposal Systems.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSVECTION FORM
PART C ''
SYSTEM INFORMATION
PTopeMAddre":83 Katherine Road Centerville ,Mass .
Owner: Harold D. Dick
Dame of kupe`bon:8/4/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow:__/,jjQ_g.p.ddbedro
Number of bedrooms(desi n Number of bedrooms(actual):_g
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) �(Y,e�s or�_:: If yes, separatelnspaction.required -.
Laundry system Inspected (yejor no)
Seasonal use (yes or no):YI
Water mater readings,If ava table (last two year's usage(gpd):
Sump Pump(yes or no): �
Lest date of occupancy:
COMMERCIALANDUSTRIAL:
Type of establishment: /¢
Design flow: d ( Based on 15.203)
Basis of design flow /Q
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes of no)"
Non sanitary waste discharged to the Title 5 system: (yes or no), -
Water meter readings,If available: /V
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RE RDS source of nformati //
YYrr��ccrr,, f/� /V a l�`�NZ�1 .^1
System pump d as part of inspection: (yes or no)
If yes, volume pumped: gallfns
Reason for pumping: meal
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, anach previous Inspection records,If any)
I/A Technology etc. Attach copy of up to data operation and maintenance contract
Tight Tank _Copy of DEP Approval
Other
APPROXIMATE AGE of all components, datu i;rstalfed-if known)-and sowce af4oforrnation: _ •
Sewage odors detected when•arriving at the site: (yes or no) '
revised 9/2/98 Page 6of11
Macomber Customer History Screen 8/4/99
Customer number 2908
Company Name Create New Invoice
Customer Name Gail Dick 778-4694., Find Invoice
JobAddress 83 Katherine Road --
JobCity Centerville Find Customer
Job3tate MA Add Billing Address
JobZip . 02632
Tel 778-4F94.,
Print History
Fax Customer List
Billing Address 142 North St
Print
BillingCity Acton
BillingState MA
BillingZip 01568
Notes 1117189 pump 1 105.00 11/21/89
5/21/93 maint pump 145.00 6/11/93
-Alp .,l-TA
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PT0pertyAd&s."iB3 Katherine Road Centerville ,Mass .
0w7w: Harold D. Dick
Deu of Inspection: 8/4/9 9
BULLDL40 SEWER:
(Locate on site plan)
1f
Depth below grade:-k
Material of consuuctio : cast n 40 PVC_other(explaln)
Distance hom Fily s water uppl well or auction line
Diamstor
Comments:(condition of Joints, venting, evidence of)eakage,-ste.)
Joints appear
S C TANK: QY►i
(locus on site plan)
Depth below grader
MaterlaJ of construction:concrete�st&WaFiberglass o!L4Polyethylens4L4other(explaln)
If tank Is instal, list age 13.ago.confi4mad by Cortificate of Compliance (Yes/No)
Dimensions:
Sludge
Distance from top of sludge to bottom of outlet ise or baffle-
scum thickness: AA a
Distance from top of scum to top of outlet tss or baffle:�rA
Distance from bottom of scum to bonom of outlet ise or baffle:_4
How dimensions were determined:
Commsnts:
(recommendation for pumping, condition of mist and outlet tees or-baffles, depth of liquid level In relation to outlet invert, cGucturb"nte(;ritti
evidence of leakage, etc.) Pump main rPG4nnn1 ravary 2 'A yonra
Cesspools
GREASETRAP: f
(locals on site plan)
Depth below grads:
Material of consuucdonw4concrat.&metalo0*kIbsrglss44,APolysthylsnsr(/dotherlexplein)
Dimensions:
Scum Wcknsss: �
04t.ancs from top of scum to top of outlet too or baHls:.._ & I,�
Distance from bottom of a um to bonom of outJst tee or battle:R0
Date of last pumping:
Comments:
(recomntsndadon for pumping, condition of Inlst and oudst toes or baffles, depth of liquid level In relation to outlet Invert. ruucnual integnt�
evidence of leakage, etc.)
-Grease trap
revised 9/2/98 Page 7ofII
TOWN QF BARNSTABLE
-,�^.,ATION T� SEWAGE # .
VIl,LAGE ' '� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �yy'�F�
LEACHING FACILITY: (type)AAGY (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 Leachjng Facility(If any wetlands st
within 300 feet o ea g f ' ' ) Feet
Furnished by f
r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM.tnsP`ECTION FORM
PART C
SYSTEM INFORMATION (continued)
` Pr Address: 83 Katherine
e Road Centerville Mass .
owns.: Harold D, Dick
Data of Irupecdon: 8/4/9 9
TIGHT OR HOLDING TANK:l&1(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grader
Material of construcdon:49concreteametaWAFiberglas4,Polyethylene,4other(expiain)
AtA
Dimensions:
Capacity: gallons
Design How: gallons/day
Alarm present
Alarm level: Alarm In jIn working order: YesUA NoAO
Date of previous pumping: It
Comments:
(condition of Inlet tee, condition of alarm and float switches, etc.)
Tight or holding hanks ape eet—present .
DISTRIBUTION BOX:/A&Q1
(locate on site plan)
Depth of liquid level above outlet Invert:_
Comments:
(note if level and distribution is equal, evideno-s of solids carryover, evidence of leakage Into or out of box, etc.) — —
Distribttti nn ALLY ; 2 not—Przeseet .
PUMP CHAMBER:N4W,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms In working order(Yes or No)
Comments:
(not@ condition of pump chamber, condition of pumps and appurtenances, etc.)
limp chamber JR not nrecent
revised 9/2/98 Peec8of11
F
._ SUBSURFACE SEWAGE DISPOSAL SYSTEM IIJSPECTION FORM
PART C +-
SYSTEM INFORMATION (continued)
PropertyAddress:83 Katherine Road Centerville ,Mass .
Owrw: Harod D. Dick
Date of inspection g/4/99
SOIL ABSORPTION SYSTEM(SAS)L
(locate on 31te plan,If possible:excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:,
leaching chambers,number:
leaching galleries,number:_
leaching trenches,number, length:
leaching fields, number, dimen ions:
overflow cesspool,numbs
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy snnrl to mpdi ,im f i nA canrl No signs of hydr-aulle gailere
CESSPOOLS:_
(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: 14
inflow (cesspool must be pumped as part of Inspection)
o
.Lnfiow cesspool was pumyed . No water intAsion took pla e .
Comments:
(note condition of soil, signs of hydraulic failurs,level of.ponding,condition of,vegetation, etc.)
Same as above
PRIVY:A
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:,
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
Privy is not present
� 4
revised 9/2/98 . P2ee9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEV4INSPECTION FORM
PXRT C
SYSTEM INFORMATION(oorttinuad)
NopoMAd-ck"4: 83 Kathexine Road Centerville ,Mass .
*Owr : Harold D. Dick
D.0 or UuPoc'd�: 8/4/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at Fait two permanent reference landmarks or benchmarks
locate all wells wlthln 100' (Locate where publlc water supply comas Into house)
Na�
revised 9/2/98 e4e�Ioorlc
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECM6N FORM
PART C '
SYSTEM INFORMATION (continued)
P,openyAddresa: 83 Katherine Road Centerville ,Mass .
Owrw: Harold D. Dick
Date of 4upecdon:8/4/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater r
USGS Date websits visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
I
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
�served.Site(Abutting propert bservatlon hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
ecked pumping records
Checked local excavators, Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used water contours map .
Gahrety & Miller Model
12/16/94
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revised 9/2/98 Page 11orn
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�1 TOWN OF Barnstable BOARD OF IIEALTIISUB +
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h-• T••.':: SUItFACF SEWAGE f)I f�U,SAL SYSTEM INSPECTION FORM - PART D^- CEIt'fIFICATION
Tl•1
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 83 Katherine Road Centerville ,Mass . '
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Harold D. Dick
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & Son Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 .
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
Y System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
hea1Lh or the environment as defined in 310 CMR 15 . 303 , Any failkire
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have cone cted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically doted on PART C - FAILURE
CRITERIA of this inspection form .
LInspector SignaturAX1 Date `
copy of t}lis ert.ification must be provided to the OWNER, the BUYER
ere applicable ) and the BOARD 08' )iEAL1')l:
f the inspection FAILED, the owner oroperator shall uin one year of the date of the inspection, unless allowweddortrequiredhe m
rwise as provided in 3.10 C�jn 16 , 305 .
_ partd .doc