HomeMy WebLinkAbout0126 OLD POST ROAD (CENT.) - Health (2) 126 OLD POST ROAD, CENTERVILLE
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UPC 12543No.53LOR
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0 mmonweatth of Massachusetts - - -
C act
_ John
E m nta Aff
f rune 'c Inspector
.O V tit Ins o nvl S_ mf'iCe t E Title Executive D.E.P. T _
_ eP P
P,O. Box 2119 -
�e:�artment Of Teaticket;.MA 01536
Environmental Protectfon .. (508)564-6813
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPEC_TION FORM J
PART A
---_ CERTIFICATION
Address of Owner:
Property Address: 126.old Post Rd.Centerville,Ma "t.
(If different) ,, 5 f 0in I
Date of Inspection:813v9s A]Simpson b ` 7
Name of Inspector:John Grad V�
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
_ Conditionally Passes -
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 8131196
The System Inspector shall submit 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 CM 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 11115195) _
-5500
One Winter Street ,• Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION-FORM =
PART A
CERTIFICATION (continued)
Property Address: 126 01d Post Rd.Centerville,Ma _
Owner: Al simpson -
Date of Inspection:8131196 — -
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 1S
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 1.00 feet to a
surface of water supply or tributary,to a surface water supply.
The system has aseptic 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:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
_ 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
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SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM -
PART A-
CERTIFICATION:(continued)
P ro pe rty Ad d ress: 125 Old Post Rd.Centerville,Ma -
Owner:. Ai slmpson _ .
Date of-Inspection:813U96 -
DJ SYSTEM FAILS(continued) ._
Static liquid level in the distribution box above outlet invert due town 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 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
nalyzed to be acceptable,attach copy of well water analysis for
acceptable water quality analysis. if the well.has been a
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 II of a
public water supply well)
shall bring the system and facility into full compliance with the groundwater treatment program
The owner or operator of any such system
requirements of 314 CM 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
. t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.'.'-. l
i PART.B —'
CHECLIST - —
Property Address: 126 old Post Rd.Centerville,Ma - -
Owner: Al Simpson _
Date of Inspection:.8131196_ - C
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: -
NaAs 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) „. T
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM .
PART C
SYSTEM INFORMATION -
Property Address: 126 Old Post Rd.Centerville,Ma
Owner: -AI slmpson -
Date of Inspection:8131196
- - FLOW CONDITIONS
RESIDENTIAL: _ -
-Design flow: 330 gallons
_ -Number-of bedrooms: 3
Number of current residents: 2 -
-Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: nla
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) Na
Water meter readings,if available: Na
Last date of occupancy: Na
OTHER: (Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection: (yes or no)Yes
If yes,volume pumped: 1000 gallons
Reason for pumping: Maintenance.
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:
1983
Sewage odors detected when arriving at the site:(yes or no)
(revised 11115195);
`J•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- _ PART C
SYSTEM INFORMATION (continued) -
Property Address: 126 Old Po
st Rd.Centerville Ma. ,
P Y_. Owner: AI Simpson-
Date of Inspection Mll96 --
---SEPTIC TANK: X _ - -
(locate on site plan); -
Depth below grade: 14'
- Material of.construction:X.concreate_metal FRP_other(explain) r -
Dimensions: L 8'r H 5'7'W 4'10•
Sludge depth:5'-
Distance from top of sludge to-bottom of outlet tee or baffle`. 22" _
_ Scum thickness:7'
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: 11•
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 stucturaliy 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:rda
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.)
Na
(revised 11115195)
6
a
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.r.4^
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION_FORM
PART C
SYSTEM INFORMATION.(continued),
- Property Address: 126 Old Post Rd.Centerville,Ma - -
Owner: Al Simpson
Date of Inspection:$0196 `
TIGHT OR HOLDING TANK:
(locate-an site plan) -
Depth-below grade: n1a —
Material of construction:_concrete_metal_FRP other(explain)-:
Dimensions: Na b. -
Capacity: n1a gallons _ -
Design flow: n1a gallons/day
Alarm level: n1a'
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.) ,
n1a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
Na
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)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- - - 'PART C.
SYSTEM INFORMATION(continued)
-- - Rd:Centerville Ma.Id Post
e Add
ress: 126 O ,
Property P Y
Owner: - AI Simpson _
Date of Inspection:8131196
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site.pian,if possible;_excavation.not required,,but may be approximated by non-intrusivemethods)
If not determined to be present, explain:
Na _
Type: -
leaching pits, number: 1,000 gallon leach pit
leaching chambers,number:-nla
leaching galleries; number: n1a
leaching trenches,number, length: Na
leaching fields, number, dimensions:n1a
overflow cesspool,number:nla
Comments: (note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The leach pit is structurally sound and functioning properly, -
CESSPOOLS:_
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nta
Depth of solids layer: nia
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)
n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.}
n/a
PRIVY:_
(locate on site plan)
Materials of construction: 1-a Dimensions: n1a
Depth.of solids: Na
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PrivyComments
(revised 11115/95)
g
- — - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -
PART C SYSTEM INFORMATION(contlnued)
Rroperty Address: 128-Old Post Rd.Centerville;Ma I
Al sim son
- Date of Inspectlon:8131190.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
-- include ties to at least two permanent references landmarks or benchmarks
- locate all.wells within 100'
t
QA
g� `O
DEPTH'TA GROUNDWATER
Depth to groundwater:12 feet .
method of determination or approximation:
USGS Maps and Charts
(revised 1.1115195) _
9
i-
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® ��((//F H pTH
...........OF..... ... .1.!!�/� ..... '` .......................................
Appliraiiun for Disposal Vur Tuns rnrtiun rumit
Applications hereby mad for a Permit to Construct ) or Repair ) an Individual Sewage Disposal
syst t��.�:LI).51 .---.^ �....!andexva�G� Lot.K.....---- --
..
dress A . .......
/
Owner dd
W ,p��
............... .... .... = -----..........•.... .. ..... _ f l. . ....
��— b Ins staliej Address /(� p
d Type of Building U'�1n e.N" ize Lot__1___k_L..(.&...Sq. fee
0-4 U Dwelling—No. of Bedrooms.......... .....Expansion ttic ( � Garbage Grinder (h
' 1 Other—T e of Building No. of persons......... .............. Showers Cafeteria
a YP g (� ( )
Otherfixtures ... -------------------------------- -----------------------------------------------------•--•---------------•-•-----------------
w Design Flow.................... ._....._..gallons per person per day. Total daily flow.._.. �..............._.......gallons.
WSeptic Tank—Liquid capacity/��.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching ar •.---_____.-----sq. ft.
z Other Distribution box J,,j DosinggtnkPercolation Test Resul Performed by._._. � _. _l�!. ................................ Date.rf__ C _. ......
Test Pit No. 1........L..minutes per inch Depth of Test Pit-----r_ -.... Depth to ground
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..�// ----•------------- ---------•-._..............----•-----••-•-•----...--•-•-......•---•--•.••---
O Description of Soil......... L•��—
x ......----•-••------•-----•-•------••--..•---
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-- -----------------------------•---------•••-•....----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ' accordance with
the provisions of AITIL 5 of the State Sanitary Code—The undersigned further agre of o ace the system in
operation until a Certificate of Compliance has4bn issued by r of hlth
Signe -�� ------- --•
Date
ApplicationApproved By............. _...... I . ... ............................ ---....------ ------
Date
Application Disapproved for the following reasons.................................................................................................................
••.......-•-------------•-•-••-•-...•----..._.__...-----------•-••-----••-----••-----...•---------------•-----------•--......---•-------------------------------------------------------------••-••-•---
Date
PermitNo......................................................... Issued.......................................................
Date
No........................ Fim..............................
THE COMMONWEALTH OF MASSACHUSETTS
r BOAR® OF HEALTH
7- ..........."OF...... � .. ...............................
Atipfiratiun for Dispaii al fur Tomitriirtiun ramit
Application is hereby made for ajP�ermit to Construct ) or Repair ( ) an Individual Sewage Disposal
.........`.«..«:...«. .J_." ...................... .._.._._... ..................................................................................................
Location dress f,�or Lot No
... ...............�t . .....-�1.L. .�.......�!i.......:�?. ��G_.... !✓ -� .....
-«��- �-��+sT,�:.�ar,�f _ ----
Owner Address
/� ..
...... ........... ..........."...�...._ ...l 1.. -Z!_.-i .�:r::d.... -�''`_�«_ .� /7./�i/ii��t,•Z1,:.......
......... ....y.... _ ...... .. ,
Installer Address �i '
Type of Building Size Lot__/_ 1_li. /r ....Sq. feet
Dwelling—No. of Bedrooms......... ...........................Expansion tic ( Garbage Grinder
Other—T e of Building No. of ersons_______. Showers — Cafeteria j
Pa YP g -••••••-•-•• P ( l )
P4 Other fixtur s .
G: Design
Tank—Liquid Li uid.ca aci�L'.% .gallons Length n per day.
daily floDia r�� gallons.
W g P P P Y Y .. •--
P9 P Y -------•--..... Depth................
Disposal Trench—No. -------_--•------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank ( / )
aPercolation Test Resins Performed by.... _:[. d..-�. ..... .............................. Date- ..L.... ....�.. .......
Test Pit No. 1........ ..minutes per inch Depth of Test Pit.....t��� r_. Depth to ground water--_,?VjxV ._.__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._--------•----....___-
t� ; -• ..
O Description of Soil........ ". _.........I....i,��*a .....�`k-4 .�-=------------------ I - - -
W -•••-•--••••••---•----------••--•-•-••-•-•--•-•••••••-•--•••---•----•---•--••---••••-•----•-----•••-----••-••-----------------••-----•------•••--•-••--•-••-----••--•-••......--•---••---•--...........
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
-•-------------------••--•----•......._........_..-------•-•-----------...........-•---------.-------------•---•••-•---------•-••••-•-----•-----••••...................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System inaccordance with
the provisions of T i -, s TI 5 of the State Sanitary Code— The undersigned further agree of i0 place the system in
operation until a Certificate of Compliance has been issued by they board•of h lth.
�-
..._" ...
A lication Approved B _ ---^-,✓� / ..�//fit
L
Date
Application Disapproved.for the following reasons--------------------------------•-----------------------------•-----------------•---....._.........------....---
...-------•---------•..............•---------------••----...-•-----•--•----------.....--------------.......-----------------------------•-----------------------•----------------------------------•.....
Date
PermitNo......................................................... Issued.................
Date
THE COMMONWEALTH OF MASSACHUSETTS
J...-� BOAR OF HEALTH
....................I.................OF...... �'4� . ......................................
(9rdifirate of Toutphattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repairedby ( )
/
Install at............................................... .......................................... -�,-4� wr. -_A:�_�------------------------------------------------------------
has been installed in accordance with the provisions of TI ,_5,?f The State Sanitary Code 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.
�h
DATE............................................ .... Inspector......... ........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARF HE LTH
.:............ �.-.. ........ ...................................
No......................... FEE........................
Map nr�iun rr it
Permission is hereby granted ..... r '. ........................... .......
to ConstrVu ( ) or Repair ( ) an Ind•vidual Sewage Disposal System
r'
Street I
as shown on the application for Disposal Works Construction g mit No.,,,' .. Dated*--------------------------
B��S..� ... oard of Health
DATE-------------------------------••--• --------...............:
FORM 1255 HOBBS & WARREN, -INC., PUBLISHERS
LOCATION SEWAGE PERMIT NO.
aa- co"
as --dal
VILLAGE
IN TA ER'S N E i ADDRESS
r
i U 1 L D E R OR OWN ER
'91,08 "" J *a I
OwAjc%j;en�
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
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a
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