HomeMy WebLinkAbout0127 NOBADEER ROAD - Health 127 Nobadeer Road
Centerville.. P
A._. 251. 228T00
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Omrford, NO. 2 0 5 1/3 ORA
181; : 10%
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• \ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENviRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A ,
CERTIFICATION
Property Address. a-7 \iclo&�SEe& ecad
Owner's Name: PU►fN Q}{
Owner's Address: 38 R% _0
Date of Inspection.
Name of Inspector.(please print) W I 1 1 i am E._ .Rcilhinson Sr,
Company Name: William E. Robinson Septic Services
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number.- (So81 775-877-5.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate.and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems_I am a DEP
_ approved system.inspector pursuant to S "on 15340 of Title 5(310 CAM IS.M)_ The system:
Passes "
Conditionally Passes
Needs Further cation by the Local Approving Authori
Fails
Inspector's Signature: /42A
Date;
�b
The system inspector shall submit a copy of this inspection report to the Approving Authority(Soard?tif Neatth oW 5; .
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design fia of 10,000 ' .
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regio ice of the
DEP.The original should be sent to the system owner and copses"sent to the buyer,if applicable,and a approft >'.
authority. C
- j M
Notes and Comments ".
"••This report only describes conditions at the time of inspection and under the conditions of use at that
time_This inspection does not address how the system will perform its the future Under the same or different
conditions of use-
'title 5 Inspection Form 611 S20t10 page I
LP
5—lo
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +
PART A
CERTIFICATION(continued)
Property Address: ID-7 WC_ ee�L
Owner: Y-e-
Date of inspection:
inspection Summary: Check A,B,C,D or EIALWAYS complete all of Section D
A. System asses:
I have not found any information which indicates that any of the fat-tare criteria described in 310 CM
15.303 or in 3 10 CMR 15.304 exist`Any failure criteria not evaluated are indicated below,
Comments:
II_ System Conditionally Passes: J
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 Neal tit,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements If`Prot determined-please
explain_
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial inf Itration or exfiltration or tank failure is (wheimmither
existing tank is replaced with a complying I . s system will Pass inspection if the
P ymg optic tank as approved by the Board of Health
`A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due twb-oken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass
approval of Board of Health): inspection if(with-
broken pipe(s)are replaced
obstuction is remove d
disnnbution box is leveled or replaced
ND explain:
The system required pumping more than 4 .
Pass inspection imtes tt year due to broken or obsts�cced
P if(with approval P4s)•The m will
( PP of the Board of Healtitj: �e t!
broken pipe(s)are replaced
obstruction isRtaovcd
ND explain:
'Page 3 of i 1
OFFICIAL INSPECTION FORM:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
DART A
CERTIFICATION(continued) .
Property Address: K)o\CGUL�ee2
P.,E Q,+C'Vi 11 Q�
Owner• Yey�v-- COt-t�
Date of Inspection: / ;
C. Further Evaluation is Required by the Board of Health: f j
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.363(l)(b)that the.
system is not functioning in a manner which will protect public health,safety_andthe environment:
— Cesspool or privy is within 50 feet of a surface water
_____ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the-public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet.of a
surface water supply or tributary to a surface water supply.
— The system has a septic.tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS,and the SAS is less than 100 feet but 50 feet or more frmfl a
private water supply well,• Method used to detettnine distance
•`This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
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Page 4 of I l
OFFICIAL INSPECTION FORR'I—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: MCkaLA42e�
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes NoJ
_ ! ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Dischargc or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
logged SAS or cesspool
Static liquid level in the distribution box above-outlet invert due to an overloaded or clogged SAS or
�esspool
iquid depth in cesspool is less than 6"below invert or,available volume is less than%day flow
4 time in the Iasi .NOT due to clogged or obstructed i e s .Number
Required pumping more than sp {)
q P P g
gg P
/of times pumped .
_ t/ Any portion of the SAS,cesspool or privy is below high groundwater elevation.
Any portion of cesspool or privy is within 1001eet of a surface water supply or tributary to a surface
✓water supply.
Any portion of a cesspoo[or privy is within a Zone l of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
7,�Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kato
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free-from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
/��(Yes/No)The system fails.I have determined that one or more ofthe above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(11e following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply - --
_ T 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
if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed_The owner or operator orany large system considered a
significant threat under Section E or fatted under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page-5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address
Owner: YC'd t n Li n
Date of Inspection: S�r�r�
Check if the following have been done.You must indicate`Yes"or"no"as to each of thz following: =
Yes
No Pumping information was provided by the owner,occupant,or Board of Health ,
Were any of the system components pumped out in the previous two weeks? P '
_ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?,.
✓ Were as built plans of the system obtained and examined?(if they were not available note as NIA)
�C S Was the facility or dwelling inspected for signs of sewage back Up? ,; +
✓ Was the site inspected for signs of break out? ;
�! Were all system components,excluding the SAS,located on site?
V1 — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition °
of the b-aines or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the SoiE Absorption System(SAS)an the site has been determined based on:
Yes o
Existing information.For example,a plan at the Board of Health.
Y
_ Determined in the field(if any of the failure criteria related to-Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b)j
. b r
5
t
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 a7 �Oe
t—V n tic1 '
Owner. Y�'1El `l
Date of Inspection: j
FLowcommoNs
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15-203(for example: 110 gpd x fl of bedrooms):
Number of current residents: !
Does residence have a garbage grinder(yes br no):'
Is laundry on a separate sewage system(yes or no):,j!2_ [if yes separate inspection requiredj
Laundry system inspected(yes or no):N��
Seasonal use:(yes or no): J?S j /
Water meter readings.if available(last 2 years usage(gpd)): y/d-7 � u1Oft &' a s
Sump pump(yes or no):/V0
Last date of occupancy: r -}t-
COMMERCIAIIINDUSTRIAL �)
Type of establishment:
Design flow(based on 310 CMR 15.203):_ gpd
Basis of design flow(seatslpersonslsgft,etc.):
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meter readings,if available:
Last date of occupancy/use: -
OTHER(describe)--' '
l
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
-'00,Septic tank,distribution box,soil absorption system '
Single cesspool
_._Overflow cesspool
—Privy
—_Shared system(yes or no)(if yes.attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner) _
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
7 �3 771 „,. 1'cce>-A
Were sewage odors detected when arriving at the site(yes or no):�t
6
1'arc 7 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFO101ATION(condnucd)
Property Address: 12�
Owacr: �e Vi N yule
Date of Inspection: 3 ;4 a 3 nj
BUILDING SEWER(locate on site plan)
Depth below grade: j
Materials of construction:_cast iron ✓40 PVC - outer(explain):
Distance from private water supply well or suction line:
Comments(on condition of juutts,venting,evidence of lcakagc,etc.):
-t t a¢t.A ` A/o.,E I-e-,=
SEPTIC TANK:✓cate on site plan)
es '
Depth below grade: Id
Material of construction: ✓ucretc_meta{ fiberglass_polyethylene
_ouxr(explain) _
If tank is ntetal list age*._ is age conftniied•by a Certificate of Compliance(yes or nu):`(attach a copy
certificate) of
Dimensions: /qL-r, ;
Sludge depth:_ ICP
Distance from top of sludge to bottom of outlet Ice or bathe: 5'•J +
Scum thickness: /"
Distance front top of scum to top of outlet Ice or baffle: 7
Distance from bottom of scum to bonont of outict tee or batlle: _
I tow were dimensions deterutincd: cPe t*.f epAia .>M,, yv.e r✓✓..r y3
Comments(on pumping recommendations,inlet and outict tee or baffle conditicn,structural uttegrity, liquid levels
as related to outict invert,evidence of leakage.etc.):
-!a-t< -4& .4E r .4 tl.{ Abbt G/tr yr� �+� . !gin% S Lw✓f �t (Jv� S.
,CIA J
: —4z— te-c i c-4- (k Yfw.,. df J✓14t �'�'a...e n. l fG i ri•y .:.t s7 i f .S�Putr=Jvrq,�� Ju,,v�/
GREASE TRAP: C7�. Iloltatc on site plan)
T (�,
Dcput below grade.
Material of construction:—coacrcte—metal fiberglass�rolyc0tylene outer
(explain): ___
Dimensions:
Scum thickness:
Distance from lop of SCUM to top of outlet tee or baffle:
Distance front bottom of scum to bottom of outlet(cc or baffle:
Datc of last pumping:
Continents(on pumping rccontntatdatioas,inict and outict tce or baflic eonditiva,structural integrity,liquid levees
as related to outlet invcn,evidence of lcakagc,etc.):
7
f
9ofIt 4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continucd)
perty Addres0 17 (gyp k
n c r: Kept!�10 to
c of Inspccilon:
�!
aIT or HOLDING TANK: N (taitk must be pumped at tune of inspection)(locate en site plan)
M below grade:
serial of construction: concrete metal fiberglass`pvlyelhylene other(explaut):
acnsions:
mcity: Rations
sign Flow; gallons/day
Sul present(yes Of no):
nu level: Alann in working order(ycs or no),:
to of last pumping:
mrnenis(condition of alarm and float switches,etc.):
STIl10UT10N UOJi: N/ f present must be opertcd)(locate on site plan)
p►ll of liquid level above outlet invert:
-nunenis(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
tkagc into or out of box,ctc.):
JAIP CUAAIDER:Je(toeatc on site plan)
imps in working order(yes or no):
larms in working order(yes or no): —
ontnlenis(note condition of pump chantbef,condition of pumps and appurtenances,etc.):
Page 9 of I I
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: !a7 Nobee� 2 -
til�}Q,� 'L
Owner: 11�n 1
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): �/ (locate on site plan,excavation not required)
If SAS not located explain why:
Typ ._
leaching pits,number.
leaching chambers,number_
leaching galleries,number:
leaching trenches,number,length:
leaching Gelds,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure.level of pondin„damp soil,condition of vegetation,
etc.):
�l C�+''! - n� I..Sk �/c�ch•���..- S�-•u .S`:��f „ 1,,, �.lGL'J. f"'�' tsc.l�i .f'Ddrs!
_ � l� �17 LMI� /.ID �1`(e y J/ I�JT AJL3ILY/IG T+i!'f✓L• .
4
CESSPOOLS: N�(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: ¢
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR1Vl': /�cate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc-):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: --t Y� ,
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building.
a t
, 93 ' `
37 Cam'
A 3 r 07'
�3 3 Si
10
',age'11`of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: P'7
e.�1J42X--\6 �l
Owner. it i J Cz)�4 rvc--f
Dale of Inspection: �f!5�fi�►
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water c95, feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property(observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
tl
C0\L110N-WEALTH OF MA,SSACHLSETTS
£ _ t EXECU TINE OFFICE OF E.N-mo.xmE\TAL A.FF_MRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE%%-LNTER STREET. BOS T ON 11Lk 0210t t61:j 24255(w
TRi'DY COXZ-
Secretary
ARGEO PALL CELLLCC! DAVID B STR-uc
Governor Corwmiss:one-
SUBSURFACE SEWAGE DISPOSAL SYSTB 4 MtSPEC ION FORM
PARTA
CERTIFICATION
Property Address: 127 Nobadeer Road N"f1e Ot D'"nef dE; a ne t•'i l l iams
Address of Owner.
Date of Inspection: Centerville , r t
Name of Inspector:(Please Print)Wm. E. Robinson S r.
I am a DEP approved s MI inspector to Section 15.340 of Tide 5(310 CMR 15.000)
Compny�: Wm. E . Robinson Sep is Service
Ma1ng Address: Pd Box 0 9. Centerville , MA
Telephone Number:
CERTIFICATION STATEMENT
1 certify that 1 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:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails or
Inspector's Signature: Date: _ -
The System Inspector 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
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
F �
OCT 2
Yeti:= se Pape lorll
_ .. V_: --led o-Recwird Pam,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Imp"Address: 1 2 7 Nobadeer Rd. , Centerville
Owner: �,,
Date of Ins iitacw-i 11 i am
INSPECTION SUMMARY. Check fA,J B, C, or D:
A. SYS PASSES:
,
1 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. YSTEM 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.
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance lattached)indicating that the tank was installed within twenty 120)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 N the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
i
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
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if twith approval of the Board of Health):
broken pipets)are replaced
obstruction is removed
revised J' /2/58 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:127 Nobadeer Rd. , Centerville
Owner: A. Williams
Date of Inspection:
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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING 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 1 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 (approximation not valid).
3) OTHER
PSiQc3orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION feorttinued)
Property Address: 127 Nobadeer Rd. , Centerville
Owner:
Date of Insp4fionWi 11 i am
D. SYSTEM FAILS:
You mus�indieate either "Yes" or "No" to each of the following:
I ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility-or system component due to an overloaded orelogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the 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 I 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 YSTEM FAILS:
You must indi ate either "Yes' or "No* to each of the following:
The ollowing criteria apply to large systems in addition to the criteria above:
The ystem serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
healt 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 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 II of a public
water supply well)
The owner o 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 information.
revised 5/2/58 PaRr4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 127 Nobadeer Rd. , Centerville
Owner:Date of H1 AA oae//toti:���77illiams
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
V _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
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:
Existing information. For example, Plan at B.O.N.
_ 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))
A/ _ The facility owner (and occupants,if differertt from owner) were provided with information on the propermaintenaar."f
Subsurface Disposal Systems.
rev_isec °i 2/9E
Psec 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: 1 27- Nobadeer Rd. , Centerville
Owner: A Williams
Date of Inspection: g ��
FLOW CONDITIONS
RESIDENTIAL:
Design flow: :T6 6 g.p.d.ibedroom.
Number of bedrooms (design): 3 Number of bedrooms (actual):3
Total DESIGN flow-� C
Number of current residents:
Garbage grinder(yes or no):
�
laundry Iseparate system) lyes or no)Ad;- If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):Zl--19
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no)/��O 11998-1 999 54r 000 gal.
Last date of occupancy: 1'6-<'
C MERCIAL/INDUSTRIAL:
Type of establishment:
Desig flow: gpd ( Based on 15.203)
Basis f design flow
Greas trap present: (yes or no)_
Indus ial Waste Holding Tank present: (Yes or no)_
Non-s nitary waste discharged to the Title 5 system: (yes or no)_
Wate meter readings, if available:
Last ate of occupancy:
O R: (Describe)
Last ate of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
i0
a
System pumped as part of inspection: (yes or no)/L 0
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF S TEM
eptic tank+distribution bozisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records;if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information: ^
Sewage odors detected when arriving at the site: (yes or no) O'' 0
relliSeu G L;i�� Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 1 27 Nobadeer Rd. , . Centerville
Owner:
Date of Inj a -Ai 11 i a) S
7 X IS.—
B ILNG SEWER
ILo DI to on site p :
Ian)
Dept below grade:_
Mate ial of construction:_cast iron_40 PVC_other(explain)
Dist nce from private water supply well or suction line
Die eter
Co ments: (condition of joints. venting, evidence of leakage etc.)
SEPTIC TANK:_
}locate on site plan)
1
Depth below grade: �
Material of construction: Lt`oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth: I
Distance from top of sludgelto bottom of outlet tee or baffle:
Scum thickness: t6'—G t
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet r-tee or b ffle:
How dimensions were determined: el
r Lov /b iL 1
:omments:
(recommendation for pumping, condition of inlet and outlet or baffles, depth of liquidlevel in relation to outlet invert, structural integrity,
evidence of leakage, etc.) A. I'e G V�
GREASE P:
(locate on s e plan)
Depth below grade:_
Material of cinstruction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comment
(recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence f leakage. etc.)
revise a; Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrcrkmd)
'rop"Address: 1 27 -Nobadeer Rd. , Centerville
Owner: A Williams
Date of Ins
FIT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
ilo to on site Tplan)
Dept below grade:_
Mater I of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dim ens ons.,
Capacit gallons
Design ow: gallons/day
Alarm p esent
Alarm I el: Alarm in working order: Yes_ No_
Date of revious pumping:
Comm ts:
(condi on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: O
Comments:
(note if level and distribution is equ I evidence of solids carryover, evidence of leakage into or out of box, etc.)
e �� (2� In U
PUM CHAMBER:_
(loca a on site plan)
Pum s in working order: (Yes or No)
Alar sin working order (Yes or No)
Co ments:
l to condition of pump chamber, condition of pumps and appurtenances,etc.)
reviset4 5/2 SSE page 8ortt
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cort6nued)
'roP"Address: 127 Nobadeer Rd. , Centerville
Owner: A. W il 1_i cIm s
Date of Inspection: �-5�.&—.a /
SOIL ABSORPTION SYSTEM(SAS):,/
(locate on site 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, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, si ns of hydraulic failure, level of pond'i�q. damp soil, condition of vegetation, etc.)
CES OLS:_
(locate n site plan)
Number d configuration:
Depth-top of liquid to inlet invert:
Depth of s lids layer:
)epth of s m layer:
Dimensions f cesspool:
Materials of onstruction:
Indication of groundwater:
infl w (cesspool must be pumped as part of inspection;
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate n site plan)
Material of construction:
Depth of solids: Dimensions:
Commen s:
Inote con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
=5 %C , PAR(9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icwfbnued)
Noperty Address: 127 Nobadeer Rd. , Centerville
Jw"er' A Williams
Date of Inspection: Q
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)
1 7"�
0X-C �q
� 1
1
l� a
a
Pal;c 10 of 1]
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM INFORMATION(con WWI
ropertyAddress: 127 Nobadeer Rd. , Centerville
Date of kA�Williams'J— &--0
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater�Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
1✓/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)
j3 � lq
V � V
revised 9/2/95 Page Ilof11
COMMONWEALTH OF MASSACHUSETTS
. EXECUTIVE OFFICE OF-ENVIRANMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
C
TITLE 5
OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVF I
CERTIFICATION
Property Address: 1,27. JAN .O. 8 2��3
P rh'
obade-er. Rd
eentervilte TOWN OF BARNSTABLE
Owner's Name: HEALTH DEPT.
Owner's Address: AlTyson Sylvia
same
Date of Inspection: �'�T-' I
9
Name of Inspector: (please print) W i 1 1 i am E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O' Box 1089 MAP
Centerville;' MA PARCEL
Z.'L.%moo
Telephone Number: (508) 775-8776
CAT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP
approved system inspector pursuant 7Passes
' tion.15340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Sigtiature: Date: 1A!111 2_
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaWor
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under.the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
t � I
Page 2 of 11
ASSESSMENTS
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY
SiTBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A
CERTIFICATION (continued)
Property Address'.
e r
Owner. son S 1
MI A
Date of inspection:
o ;
Inspection Summary: Check A,B,C,D or E/ALWAYS complete'all of Sect►ou D
A. /sym Passes:lave not found any information which indicates that anyof the failure criterialovdeVscribed in 310 CMR
h
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated be
Comments:
Conditionally Passes:
B. System Con Y
One or more system components as described in the"Conditional Pass"section need to be replaced or
Pass-
re- edThesyst Q►';;upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Toj
Answ r yes,no or not determined(Y,N,ND)in the for the following statements;if"not determined"please
expla'
- structurally
t is s tru
or no y'
e septic tank is metal and over 20 years old or the septic tank whether metal )
unsoun ,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health:
•A me Is
septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicati g that the tank is less than 20 years old is available.
ND exy laiin:.
Observation of sewage backup or break out or high static water level in the distribution box due tabroken or
obstru Led pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approv I of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND plain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pas inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rcmoved
ND x lai :
4 c
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART`A e
CERTIFICATION(continued)
Property Address: 12:7 Nebadeer Rd— eenterville
Allysen
Owner:
Date of Insp , -inspection: /
C- Further Evaluation is Required b the Board of Health:
9 Y
Conditions exist which require further evaluation by the Board of Health in order to determine if the system'
is fail' g to protect public health,safety or the environment:
1. ystem will pass unless Board of Health determines idaccordauce with,310 CMR,15.303(1)(b)that the
s stern is not functioning in.a manner which will protect public health,safety and the;environment:
Cesspool or privy is within 50 feet.of a surface water
Cesspool or privy is within 50 feet of a`bordering vegetated wetland or a salt marsh
i
2. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system sJunot'ioning in a manner that protects the public health,safety and environment:.
The system has a septic`tank and soil absorption system(SAS)and the SAS is within 100 feet of a
sur ace water supply or tributary to'a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone l of public water supply.
The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
rivate water supply well**.Method used to determine distance
*This system passes if the well water analysis,performed at DEP certified laboratory, for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and,
t e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
f ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. (her:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION(continued)
Property Address:
C'xantarvi 1 1 c - •
Owner:
Date of Inspection: e
D. System Failure Criteria applicable to all systems:
Yo must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS'or cesspool
ground_. -
_ Discharge'or ponding of effluent to theaurface of the: or surface waters due to an overloaded or
clogged`SAS or cesspool :.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged S`AS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than I day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped ground water elevation.
Any portion of the,SAS,cesspool or privy is below high
_ _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone Lof a public well.
_ Any.portion of a cesspool or privy is within 50-.feet of a private vrater supply well.
Any portion of a cesspool or privy is less than 100 feet.bu[greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is tree from pollution from that fapcility co tided that no other failure criteria
the pre
nitrogen and nitrate nitrogen is equal to,or p
,less than S m,p
are triggered.A copy of the analysis must be attached to this forma
( esMo)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary:to correct the failure.
E- Lar a Systems: g y y t y g d to 15,000
To be c sidered a large system the system must serve.a faci.it with a desi n flow of 10,000 gp
gPd-
You m t indicate either"yes"or"no"to each of the following:
(The f lowing criteria apply to large systems in addition to the criteria above)
yes 1bthe 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
If you h e answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of wry large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. Fhe system owner should contact the appropriate regional office of the Department.
4
i
Page 5 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IN. FORMy
PART B
CHECKLIST'`
Property Address: �rPE2 _
—Ceft�r-ville
Owner:Date of Inspection: — —013 n Sylvia
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes/ No %f
1J _ Pumping information was provided by the owner,occupant,or Board of Health,
J Were any of the system components pumped out in the previous two weeks T -
_ Has the system received normal flows in the previous two week period?
✓Have large volumes of water been introduced to the system recently or as part of this inspection?
_ Were as built plans of the system obtained and examined?(If they were not available note as,N/A) ,
— Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was''the site inspected for signs of break out?
_✓ _ Were all system components,excluding the SAS,located on site T
_✓_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth ofscum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
�/ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation,of distance
is unacceptable)(310 CMR 15.302(3)(b))
5
r -
Page 6 of 11
OFFICIAL,INSPECTION FORM ti NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART,C.
SYSTEM INFORMATION
Property Address: -1 7.7 Nobadeer Rd
Centervii ems—
Owner: Allyson Sylvia
Date of Ibspection: 4g,=/1-6-2,
FLOW CONDITIONS
RESIDENTIAL.
J
Number of bedrooms(design):. Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: /b
Does residence have a garbage OWdcr(yes or no): h� v
Is laundry on a separate sewage system(yes or no):-fy 0[if yes separate inspection required]
Laundry system inspected(yes or no):A
Seasonal use:(yes or no):,10 0
Water meter readings,if available(last 2 years usage(gpd)) 8 '2 0-=0.1'4>th�ru •1 0=23-0 2 79, 500L
Sump pump(yes or no):& -
Last date of occupancy: ate
-� � _ ,._' _ - •
C MERCIAL/INDUSTRIAL
Typ of establishment:
Desi n flow(based on 310 CMR 15.203): pd -
Basis f design flow(seats/persons/sqft,etc.):
Greas trap present(yes or no):_
Indust ial waste holding tank present(yes or no):
Non-s,nitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last d ite of occupancy/use:
OTH R(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): d
If yes,volume pumped:__gallons--How was quantity pumped determined?
Reason for pumping:
TYPYOF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all c m onenttss,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):A, 0
6
Page 7 of 11 a
OFFICIAL INSPECTION FORM=NOT"FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM H
PART C
SYSTEM INFORMATION(continued)
Property Address: 127 Nobadeer Rd
en ervi e
Owner: Allyson Sylvia ..
Date of Inspection: t 2-1<—e g—
BUILDING SEWER locate`on site plan)
Depth below grade-
cons
of cons ction cast iron 40 PVC other(explain):
Distance from tvate water supply well or suction line:
Comments(o condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:v(locate on site plan)
Depth below grade: 3
, .
Material of construction:_✓..concrete_metal_fiberglass_polyethylene,
_other(explain)
If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):_(attach a copy of'
certificate) ---.-
Dimensions: ee $^
Sludge depth: y—G
Distance from top of sludge to bottom of outlet tee or baffle: S-6 —
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: ,
Distance from bottom of scum to bottom o outlet tee or baffle: 1;Z, ,
How were dimensions determined:_0
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.
GRE E TRAP: (locate on site plan)
Depth be w grade:_
Material construction:_concrete_metal_fiberglass_polyethylene_other `
(explain):
Dimensio s:
Scum chic ess:
Distance om top of scum to top of outlet tee or baffle:
Distance om bottom of scum to bottom of outlet tee or baffle:
Date of I t pumping:
Comme s(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relate to outlet invert,evidence of leakage,etc.):
7
I
Page 8 of 11
OFFICIAL
INSPECTION FORM `NOT FOR VOLUNTARY ON FORM ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPEC _: , _..
PART C
SYSTEM-INFORMATION(continued)
Property Address:
1 2 7 Noba d .._.. .., ._..
Owner:
A1jy3D1 &y1via
Date of Inspection: /x "e
G TANK: _( must be pumped at time of inspection)(locate on site plan)
TI T or HOLDIN
Depth elow grade: concrete metal fiberglass Polyethylene ,other(explain):
Mated l of construction:
Dimen ions:
Capaci •: Rallons '
Desig Flow: gallons/day
7 Cl
Alarm present(yes or no):
Al level:
Alarm in working order(yes or no):
Date f last pumping: -
Co ents(condition of alarm and float switches,etc.):
DISTR
IBUTION BOX: v (if present must be opened)(locate on site plan)
invert:
evidence of solids carryover,any evide
, nce of
Depth of liquid level above outlet Y
Comments(note if box is level and distribution to outlets equal,any
leakage into or out of box,etc.):
PUMP CHA ER: (locate on site plan)
Pumps in workin order(yes or no):
Alarms in worki order(yes or no):
Comments(note ondition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
3.. PART-
SYSTEM.INFORMATION(continued)
Property Address: 127 Nobadeer Rd
Centerville
Owner: Allyson Sylvia
Date of Inspection: /
SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan,excavation..not required)
If SAS not located ex lain wh
_. . . P Y
TYPe
leaching pits,number:L
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESS OOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numbe and configuration:
Depth top of liquid to inlet invert:
Depth f solids layer: .
Depth f scum layer:
Dimen ions of cesspool:
Matey' is of construction:
Indic ion of groundwater inflow(yes or no):
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materia of construction:
Dimen ons:
Depth solids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 .
-
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C_;
SYSTEM INFORMATION(continued)
_.r
Property Address: 127 Nobadeer Rd _..
Centerville
Owner: Ally son Sylvia
Date of Inspection: ill'®.2—
SKETCH OF SEWAGE DISPOSAL SYSTEM
I
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
1
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 127 Nobadeer Rd
Centerville
Owner: Allyson Sylvia
Date of Inspection:�2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground watery feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: j D,6
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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Il
TOWN OF BARNSTABLE
LOCATION 47 1—J a SEWAGE#
99 �-
VIILAGE d ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. o
SEPTIC TANK CAPACITY ru Uc�a�
LEACHING FACILITY:(type)_ (size)
NO.OF BEDROOMS
OWNER f
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
i.. ........ ..... ti. a Fa'Bi... .................
THE COMMONWEALTH OF MASSACHUSETTS �r�
BOARD OF HEALTH
.......... w .. .....oF......f �-n.3_ a.11�--------------------------•--------
.
Appliration for Bispwial Workii Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ✓j or Repair ( ) an Individual Sewage Disposal
System at: /
..••----......L.07 �v /llQ�l
Location- ddress or Lot o.
. ............... ' ...................... ...12.1.....
�c�
Owner '.fyA�,ddress
W ......... ..l rL�"/��' .K.....................................
Installer Address
Type of Building Size Lot.. 0,_54-'?Y•....Sq. feet
Dwelling—No. of Bedrooms...................I........_..._.__..__..Expansion Attic ( ) Garbage Grinder ( )
PLO Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P, Other fixtures -----------•--•-•---------------------------------------••-••-••-•••-------•-•-•--••--------•--•-•----•--•••--•-
W Design Flow...................ra'- .................gallons per person per da . Total daily flow.................3_�,Q..............gallons.
W Septic Tank—Liquid capacity_/GDAgallons Length....
�f Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width_.}.... Total Length.....`............ Total leaching area....................sq. ft.
Seepage Pit No---------/--------- Diameter......, Depth below inlet.... Total leaching area.2674 S:Zsq. ft.
Z Other Distribution box ( ✓Y Dosing tank ( )
Percolation Test Results Performed by..... Date...... 1�/8 ..............
Rl f7(Test Pit No. 1....4.7—._._minutes per inch Depth of Test Pit......./2 __..._ Depth to ground water... Sl A--------
f3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix ......................•-----•-•••••-•-•••......•••--• -••••-••••......•-•--•-•--•-........_.....-•---•-•-••---•-••......•-•--•-•-•----•-•-•--•••--•-•--
�
Description of Soil-----------------D_.-..3...---T�_ ..5�163 � y'---.3_._-.a_�_.�Q �'. .� y .Glhc_C� �'--
.._
V 17....... ............................
UNature 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 iIT?1L 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ss e t and of health.
_-— igned... _ - -- - ----------------------------------------- .. ... ...
ApplicationApproved By•--••-• .••• •••••--•------••-•-------------------------••--•-•---------•---•-••......--••--••.
Pate--•---..._..--
Application Disapproved for th ollowing reasons:--.........I.....................................................................................................
--•••-••-•--.....•-••-••••....•-•------•-•••-•--••-•-•••......---••••••••-------•-•-........--•••---...•.•••••••-••••-•••••••-----------•••••-•-•••---•---••------------•-------------•----•---••••••---
Date
PermitNo......................................................... Issued-........................................................
Date
g3 _7y1
No................-....... Fm3..............................
K` THE COMMONWEALTH OF MASSACHUSETTSe-
4' BOARD OF HEALTH
J ----------- OF.......LGn. .f�.l
ApplirFation for Dhipvii al Works Towitrurtion Vamit
Application is hereby made for a Permit to Construct ( V5 or Repair ( ) an Individual Sewage Disposal
System at:
,C.-r� /� /(/v�acl���r' 1�-1.. �'��•,�cry�•/f�------•!,1�•r:!7.�_���/�-- --�-1--�5•`'•-
Location• Nddress
�L $............. / / ... f
owner
• Address
.......................................
nstaller ZT-�
a
1 Sq. feet
I
� Address
UType of Building Size Lot...Z_O.-dam .--
�-, Dwelling—No. of Bedrooms..................:5......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of ersons-_-___--_--_-__-_-__--_.- Showers
a YP g P ( ) — Cafeteria ( )
Q Other fixtures .
W Design Flow..................�5......_._....__..gallons per person per day. Total daily flow................... _.�i..s�..............gallons.
Ix Septic Tank—Liquid'capacity.lQ!?�. allons Length-_-_-�.?t Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width... Total Length._....``....._...__. Total leaching area--------------------sq. ft.
Seepage Pit No---------/--------- Diameter....... Depth below inlet.___ .-n_ .. Total leaching area.G Z.�' sq. ft.
Z Other Distribution box ( -" Dosing tank ( )
aPercolation Test Results Performed by.....e✓ �( __.! 4 ff f-� tC-�_�� �-�. Date----- l_�' Y3_____________.
/='/f 76Test Pit No. 1....<. ._.minutes per inch Depth of Test Pit14 ....... ...... Depth to ground water_-_-14�? ._...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................
- -------------•----•-••------------------ --------•---•--•••-•----------•••-•-•-------------••--•--•----•.
o { �d
Description of Soil T �L'� �' ,- rs __ �- ���_ .......ro-v- -
W
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 TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complt • has been issued by the board of health.
Signed.........................................................----------•--------------•--
Application Approved By..... _.. ...
----•---••-------•-----------•-•-------•-••-•-•------------------- ........................................
Date
Application Disapproved for the following reasons---------------•---------•---•-----------•----------------- ---•----•--•-------•-•---------•--•-•--•-•-----••••--
------.....-•-•-•-•-•--•....•-••-•---•----•-•-----••----•----...--•-•-•--....-••--•---•-•----•-•---•----•--•----•--------••------•-•....---••---------••--••-•----•-...................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................I.....OF.....................................................................................
Trr#ifirab of Touts haurr
T FY, at t Indiv ua Sewage Disposal System constructed O or Repaired ( )
by.. �CERT ..... ---•------------- ----------------•-------•-----.....-----------------------------•---------•------•--------•---
' �lJa f f Installer
at p--------------------------
has been installed in accordance with the provisions of g The State Sanii-'ar---- X r e ribed in the
application for Disposal Works Construction Permit No_________________________________________ da.ted_....: .....................................
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WIL UN ION SATISFACTORY.
DATE./�--_Z°- ••8��------------•--•------------------•---- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... � FEE........................
�i��t •�r k� �.�at�$� ilt P�lYti�
Permissioh'is here "gr ted..° ,> f_. _ __. ..............
to Construct ( ) �R ( '/<p an InDisposa� em
at No &
------------------------------......
------
Street as shown on the appli ion for Disposal Works Construction Permit No. r�F_____..... Dated..........................................
.
DATE /l .............•--•................................. Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
SlTE PLAN TYPICAL PROFILE
NOT TO SCA L E
SCALE — I ++ = 30' F+_ . �i. :�� �
lB"STD. LT WGT C.I. MH COVER
¢. 4"C.I. PIPE 4"BIT FIBER PIPE TIGHT JOINTS
OUTLET LEVEL
y � FLOW LINEo
_ �- 0 TO F/RST ✓O/N T� ' — -'- —
k �-'' OWEL L l NG 3,vJ I4 1 Z• 6 a-1 T-
-- C.I. TEE �``�z
C.1. TEE ---- .L
I i 4,2,7� Ih4� ----
I L- - --1 STANDARD PRECAST
CONCRETE I" GALLON
SEPTIC TANK i 01STRIe6IrION BOX I I
TO BE INS TA L L ED CAN
_ LEVEL , STABLE BASE. I
!� SEPTIC TANK - 5
h C t7• rAl2 c_LAS T Cv kjL• TO BE INSTALLED ON
1►Cc4.cA c��, Jp" LEVEL , STABLE BASE
-
1�7, U
�'� comic t000 G,�L • 2 //B'" To 1112" WASHED PEASTONF LEACHING PlT
E t�-I I,a TA ti k ALL AROUND FREE OF IRONS, FINES
_ BASE TO BE L EVEL
AND DUST IN PL ACE
BRICK 8 MORTAR COURES �-y --
l 3,/4" TO 1-I/2" WASHED CRUSHED
AS REOU/RED TO BRING STONE ALL AROUND FREE OF
� COVER TO GRADE_ - 24"C.I. MH COVER _ - -_^ -
IRONS, FINES AND DUSr IN �'L ACE
✓� �A� _ .__ __�\ A.ND FRAME,
3 � _
Z � 3'
^, 4„ _ _- - -- _ ` L -ACHING PIT SECTION—
Y k '\/ �f `, f� - FI FLOW LINE
INLET
1 ` d PIPE -- - -�-- — i ---� - -_ - 1, CONCRETE TO BE 4000 PSI 28 DAYS
- T-„ / 2. REINFORCED WITH 6" x 6" NO Co GA N.W M.
_16
y 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
DEPTH REQUIREMENTS
L' OPENING WITH 4-//8 4 NUMBER OF PITS REQUIRED _'9 N g
OUTER DIAMETER B ?TE • EXCAVATE 0 ELEVATION 53,0 OR LOWER AS
? NO
I-3/4" INSIDE DIAMETER
REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
+
PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN
J+ GRAVEL TO DESIGNED GRADE
+
,
4'-0 -
MIN.
�d EFFECTIVE DIAMETER
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH)
+ I
WATER TABLE
1�1 iJ !. >`2-c�U►.... D�.l A T tr t2 �n v A•t C
SOIL AND f E=i C DA T-4 -- - - GENERA L N0 TES
1 Z MIN. /1N . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
c� p
PERC. RATE � T
sF h SIDG_ LI� �SMT. ,�. �,,'
TEST BY �tzULe !-��LD (WM' V.�/_�tz�t.tlGi� l�'�SvG•) SEPTIC ?C.NK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
- - ---- PRECAST REINFORCED CONCRETE UNITS.
j p ii N G z2 t� per. 1.3 , i.l . ALL SYSTEM COMPONENTS SHALL BE INSTALLEC IN ACCORDANCE
D WITNESSED BY �.------- - ----- - ---- ---- --_-_
P14)&`7 TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR. EL.1' � �'`�_.'— DATE ' MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST PIT N0. P I�((o TEST PIT NO ,� !oj /c�i SANITC.RY SEWAGE EFFECTIVE I JULY 1977
(� C% � n" _ — O"__ __ ANY CHANGES TO THIS PLAN MUST BE C,PPROVEC B� THE
10�i5UPjsj01(r jol�/SUp�holt.. BOARC OF HEALTH
3
CoAt�SF SA►•tO �'�A'�'� CUn..t�h� h.t��..li?/G,kAv, AT COMPLETION OF CONSTRUCTION , PRlOP, TO BACKFiLLING, ' HE
BOARD OF HEALTH SHALL BE NOTIFIED FJR INSPECTION.
Map' h/' ^�� I 7' -. PITCH ALL SEWER LINES t/4" / FT. UNLEiS INDICATE
METjI P i►�! SAP
IZ' EL53•Z l_L,57-0 OTHERWISE.
& U V.) A T > rl- N O W A T fl r
DESIGN DATA
P,EDROOMS 3__.— DISPOSAL N V
EST. TOTAL DAILY EFF _� v GALS.
L EGEND _ SEPTIC TANK I O GAL
SiDEWALL AREA GAL./SO. FT
4xOC EXISTING GRADE LEACHINM AREA G NG REQUIRED ,"3.�'7 L / SQ FT SF
-'!V /�� �� C O CA �`YSTC� ,
��SO FT. .J Y �J �.7 F- J �J / L /V�'
ZONE _ "_ d ac�� FINISHED GRACE ACTUAL LEACHING AREA FOR
_ y-- _
�` �,-� !'L O. dp� INVERT ELEVATION t�.�L►�+4;4�e Lc� l(o Iq O 13A, I7 ro- � rA. �2, •N E>
DOMESTIC WATER :SOURCE ___---�--�''� • , + t� 4F Mt�f�,� — -
fit, --�--— -- - - - "
- - PROPERTY LINE /tv 9c M7�(x- 10 �i � A l�J c�♦w , Iv1�`,+'J_
PLAN REFERENCE LG 4y �� Z %/ wltu%mm t�
— _ o SCALE ' AS INDICATED DATE
- --- MEAN HIGH WATER
f n WARWICK v+ !
BENCH MARK PAT UMU h v lc7 ------ Y =- MARSH 1',`► N . l Ji ' ✓YM M N«RW/CK ASnC/AYES
, \�EGlct44E� �,�►� >��►mw
� 1 BOX 8o - NuRTH FALMOUTH
Zt>1� ti.ir5_JJ t� 4.^ , r '`� - �, „r Uz:.SSACHUSE T I,, 02556