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0157 OLD POST ROAD (CENT.) - Health (2)
157 Old Post Road Centerville P A = 209 121 Sam IN ® "2M � • wast�aa MY i No...�.�.�_�... , F�s....l ...... �;. THE COMMONWEALTH OF-MASSACHUSETTS t `f 1r M BOAR®, F ' HEA TH ... G ....................OF...-..1........................`...........--------�--...------...._................. s , A rp f ration for Disposal Workif Tonstrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t ( Q `•�� /�Locla�ior�vd�r ss S or Lot No. n yk AddressOwner .............a: --- -------- -------------------- ----- ------ .... staller Address Type of Building Size Lot..... ....: --::._..Sq. feet Dwelling—No. of Bedrooms-__�................................Expansion Attic ( ) Garbage Grinder (. ) Other—Type e of Building ............... No. of ersons....._.._.__._.......__..... Showers W YP g ------------- P ( ) = Cafeteria.( ) 04 Other fixtures -------------4..................................................................................................................................... W - Design Flow...................{$7.r............gallons per person per day. Total daily flow--__-___ -- _ ,.:.:gahons WSeptic Tank—Liquid*capacit3/'006..gallons Length................ Width Diameter Depth ...... x Disposal Trench—N _.................... Wi ___.. __.....___.. Total Length Total leaching area sq. ft. t .......... ,r . Seepage Pit No__________ ______ Diameter............ .__- Depth below m1etG .... Total leaching area.. l�....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) p ; Percolation Test Resul s Performed by...... _. _.._. _.�!lat: _ Date___ Test Pit No. 1. _ 9------ per inch Depth of Test Pit..................."Deptha�,ground water........___._.__..._,_.. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth-to ground water........................ %� . . 1'--.._pp ...... O � � -- I ----------- Description oo --• ..................... . . . .....-•------------------------------------- --------------------- - .......-_ .... -�.....----- ---- _ .....•--------U ............................................ ,.. ... - 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 TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board o•health. d_ . a� .. � /Date - �77 .. ----...-- Application Approved By----- Aaa,47__�....--.... .. ............................. f Date Application Disapproved for the following reasons:----•-------------------------------------•-------------------------------------------------------------------- Date PermitNo......................................................... Issued....:_::_ =•-------------------------------.._....-- Date N No............. FEB....!R.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD,,QF HEAL.,TH OF................ ........................ ................................................................................... Allpfiration for Disposal Warks oustrurtion "amit V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal S stem t: ........... .. ........................................ .................................................................................................. or Lot No. .. ..... .......... ......f............Owner........................................... ............................................ .Address .......................................... .................................................. ...............7................................................................................. /nstaller Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms...'3---------_----_----- .-4 ........Ex anion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ...--------------------------------------------------------------------------------------------------------------------------------------------------- Design Flow.................... .........__.gallons per person per day. Total daily flow_______--__- ..------- _a.... ..........-gallons. Septic Tank—Liquid capacit3Vib ...!?4.gallons Length................ Width._____......._.. Diameter__-_____.___._._ Depth_..._........_.. Disposal Trench—Np- -----------__--- Wid1h...... Total Length..__................ Total leaching area... Sq. ft Seepage Pit No........ ............ Diamete..AW; ..&._.,-'D"'epth below inlet....._. .._..__._.. Total leaching area.-'. q. ft.' Z Other Distribution box Dosing tank Percolation Test Resu�,S Performed by...... ... .. ....... I........ Date..,..................................... Test Pit No. 1.1.— -._.._...minutes per inch Depth of Test Pit.................... Depth to ground water..___.____.._......_.__. fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..:::._.:..:............. -It------------------------------------------------------.............. ..... .........................i....M. . . .................. _4�� � . , 4!!, ,. 0 Description of Soil... ... - ..9/ ............... .............................. .................................................... U ........................................................................ ............................................................................................................................. .......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable..............................--------- ---------------------------------------------- ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 1Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the board 5 health. _7 ........... / . . .1i . ....... ......... ........ .................... :7---------------- ------ -----, Date_-- - ----------- Application Approved By......;...... .... .. ....... �Sig-_� 7------------------------ V_ I Date Application Disapproved for the following reasons:................................................................................................................. ......................................................................................................................................................................................................... Date PermitNo.......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........I.......OF... ....................... Trrfifiratr of Tomplitturr THL6 I TOtR age-Disposal System constructed or Repaired,-YIFY That the Individual Sew by.... rl.42�............................ ... ........................ . .......................................................................................------ at... ins 4o,r....... ...... ............... ............................................... has been installed in accordance with the provisions of,T M ' of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._6,/A6,-;................ dated__/;Z_ Z r -------------.- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A,§ A GUARANTEE THAtTHE,, SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. ...7..k............................... Inspector...... ... .44.....4..a ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOAR D ,F HEALTH ............................... OF.... ................ N .........................Permission is hereby granted....___...::�,.a____-/........a..........os�alto Consquct R ir divi fil; ewag .3ey em Ois at No../--.d.r... .....7 ............................. ............................................. ........................................ _.A.�� Street 4- , 7 as shown on the application for Disposal Works Construction Permi�_�Ow.,-_ ated---- --------r......................... ......................... Board of health .......... DATE---- o%.7-7............................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ;yL•,nBa�. apor�v�' s•lavwwm�a�mwm=T�• •w.r®.r•+w.as�w.sr �.wrw+w.�werwrresrs �.� V { '� 1 *:.,a.vti;'Y. •E d j 3 xrY, Y OLD G 1 a tx z r .G,/�'.•�<7.. �G�. J" L,,/_.'-»ry� .1`f'- .i 1.:. 1 r /_U/J C..�'� � _ ._ ..'� ..leg,,.y �{ � ^4 }t .. / i -0- r A O I SOIL ` Y, S T �fi C _3-,5RE RoolI O i _FAY tie ,. ` ` �. , �.\ - h 1..1 t•• {yam � J 4 . `UP�) } ,u. 4,4 "`\ it� � .. {lll!!. - '• � : :s 1� �[; �! r j ,'•Yj � 1 f k g + I I y t</"�•��/ [_ .•_. �.�— / .1"*LvL: {/�'C�^C K ,�-i>�.���^'>�f r�?•a h..``.i,Z �'t �„ t i ai ae A7�r;R/;9 ,• � s 4� SNAG l3E /N 7 t ,. y, 1>, Z Q: E. TI TL'E 5- o9 r/rJ RR FlAPD "';,\• C7.ARA/S TAr3 L A- RUL E v f JAn4fa P^O'l RFG FO,Q ,SU8 r_.0.47rr—:,�'ULAT/ONS }" S No. 694 "; GF '-SAN7T_19,RY.. c L'✓AG` ` FX1ST1 .SaC(�A.�EJ Tl`� /� L�/�/ /�1 c a C'/„ % €�1 cvl" .t Y _J rower a �Y 71 E- S.f r .�/ti'OE �2EIR /S fPFT'5 Ff7,C-D r k : �. �9��D Ci', a [`r1AA,. S FPS T E1�fE. ETL (EEI+ , ki ,FLEY 4<2.. y`` arU ..E"E T �Pr- Obi >�r4N xr i i 3n X/S 7-ING SPOT E-LtE VATIONS px0 ;5� 4 `. !/t��; 1�iT ./ /�:'C ' ICJ o" �^T EXIST-1NG CONTOUR - -=_-O- = - TtJ, 'Lr�JF_ . Gf�.'�✓. SUN//�/ - , EG°/Jl �T/b $ i=INISHF_-'D SPJT ELEVATIONS F/NISJ4E•D C'ONT"OUR p F xi a ode sus ' V t� BOARS OF 'HEALTN.' CERTIFIED P407" PLAN ski x j A4 1{ YW Z07 � C7L c'7 J�©S T l CE,. ?TIF'Y THAT THE PPP. OS ED PI�_HAIRD J. 09PEAR Iy R L.S. `j3U/L, 1;VG' S.gC�!AVN �?N Th�IS �Lt-?/V 191 �1�l�IN �T: (Fi�,TF. 2E�� �"JI`/ lvJ5 TO T,�-IE 'OiV/NG LAWS WE:uS7- DENNJS J,ill %�1/9 S S ' e r .e 'IS T/7A9' MASS. A .. '� „ .�'f -.� / NCI'l �I !✓-+ '!_-1..i/•Y I^7 ^ti ',�•. )) r-`1 I r'•.. r�r - , it CLEAN SAND 9,19 CONCRETE CONCRETE a COVERS pVC f='/PE COVER T. i" MIN. P�TC H- j " 12"MAX. PITCH FLOW 4 CAST- /Rp N U ?_ LAYER s'. PIPE-�^11 N. �� o o o OF y8= V2 PITCF,+ I D:ST. o W o !/'1ASHED STONE PER FT Box o o i e " . (� ` 314 oa Ct " o WASHED STONE %od U GAL. o \ k p p PRECAST LEACHING o t� ° PIT OR E QUI V. SEPTIC o C� . = a5.0 TANK - GFr=� INVERT ELEVATIONS Cy 1,AYIIERT AT BUILDING 3 FT. �$•� FT //A/LET SEPTIC TAA/K . GROUND WATER TABLE OUTLET SEPTIC TANK 34.8 F7' SECTION OF INLET DISTRIBUTION BOX FT. SEWAGE DISPOSAL SYSTEM OUTLET DISTRIBUTION BOX 2242 FT. NOT TO SCALE /IVL ET LEACHING PIT %y FT. Vl /r .Ra.0_ = 7- SOIL TEST i DESIGN -KCAL CULATIONS DATE OF SOIL TEST — /Z11( WITNESSED ,BY VUMBER OF BEDRO(OMS . . . . . . . . . . . .. . e PERCOLATION RATE MIN /NCH. ¢ `- GARBAGE LISP®SAL UNIT. . . . . . . . . . . . . . . . . :. . . . ... ✓oniF� SI DEWALL AREA - GAL.IS.F. Rlcrf/,�� TAL EST//�1.�T ED FLOW. . � G qL.I DAv BOTTOM AREi9 �'' GAL S. F.33 7 /' GAL-ISR/DAY X BR EL EVAT/ON - h. i r r Q 694 ='',?k'QU/R,EU SEPT✓C TAAI! < CAPACITY. . .... 49 �GAc . —Q 4CTUAL S/HE OF SEPTIC TANi< ' Q BE /A/ TALLED. . . . GAL. �L A C.N//VG so/T(s) ` _ "� r T ,)/AMETEK .. . 8 RE•QU/RED LEACHIN(2 AREA . . . . . . . . . ' % S.F. 4 4 Fr EFFECT/VE DEPTN) AC TUAL L.EACJ4/1\/G AREA S.F. FT. EFFE'C T/VE DEPTH R/CHARD J. ®'HEARNeR.L.S FR.�. /9/ MAIN ST RESERVE L EACAV 1/V G AREA . . . . . .. .. . . . . . .. . . . `'- � � S.F. � WEST DENNIS, MASS - - : ..,. = . joa NO. 74 2-14 _ . t y �J`s7 EWA � PE T Mf N0. LO CA ION S G , VILLAGE 0&1 / !i � INSTALLER'S NAME & ADDRESS B U I*L WE R OR, OWNER DATE PERMIT ISSUED DATE COMPLIANCE : ISSUED. /�/ i Y L a c'1 e 9 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP ZO PARCEL ; LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 157 Old Post Road Centerville,MA 02632 Owner's Name:Rodger Lyman RECEIVED Owner's Address: 157 Old Post Road Centerville,MA JAN 2 . 2004 Date of Inspection: 12/29/03 Name of Inspector:(please print)Ron Burlingame T�WHOF LTH DEPT BLE Company Name: Mailing Address:58 Oak Street West Barnstable,MA 02668 Telephone Number:508-420-2050 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 Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: - / Date: !2 The system inspector shall submit a copy of this Vipection report to the Approving Authority(Board of Health or 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection• Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: - X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not 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 infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic 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 to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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 ND explain: II Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: 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 public health,safety or 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 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 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 from a private water supply well".Method used to determine 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: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 157 Old Post Road Centerville,MA 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 No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] NO (Yes/No)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. 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: (The 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 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H 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 of any 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.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection• Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ 'Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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 of scum? X _ 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 X _ Existing information.For example,a plan at the Board of Health. 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)] Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection• FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): 03 60]00® DZ?//6,9, DOD Sump pump(yes or no):No Last date of occupancy: 12/29/03 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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): GENERAL INFORMATION , Pumping Records Source of information: Home owner-septic plant Ace- C cs s p00 L C�Nsr Was system pumped as part of the inspection(yes or no):No If yes,volume pumped:_gallons-How was quantity pumped determined? Reason for pumping: \ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool —Privy ` _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contrac-t-0o 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: 23 years old-12/29/77 installed: B.O.H. Were sewage odors detected when arriving at the site(yes or no):_ Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X(locate on site plan) Depth below grade: 8" Material of construction: X 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: 1000 gallons- 6'D x 6'W x 8'6"L Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:Tape measure Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Both tees in good working condition. GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box was at working level. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: Date of Inspection• SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Two(2) 1000 gallon leaching pits had 22"of water at time of inspection. 6'deep x 6'wide with stone. CESSPOOLS: (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.): PRIVY: (locate 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 Old Post Road Centerville.MA Owner: 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. �APAJs 01F o p Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 Old Post Road Centerville,MA Owner: p i Date of Inspection: D SITE EXAM Slope Surface water Check cellar a�n Shallow wells S gg 1 ' Estimated depth to ground water 15 plus feet �t_. 01,C0 ,,, LhAA 0 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: {^ 2009 JUN 12 AM 8: 27 e)IvIsi isa and Peter bonleq 157 Old Post hOad Centerville MA. 1 45IN6 HOU51� 28'O" i 81011 91011 P p0P051�n b�CK 160113 6�� r Toll . 251011 ' -,K house bal inters 6 oc top,rail bal inters 6 " oc post s ec in 112 deck 3 bobs 6 2-2xIO botto rail 2x10 ' 5 16 " oc 16 l l �x� post hanger �x� connector----- 2xlO s girders 4 2xl0 oc x� post 2x12 ost base ledger strip ern a' ' O below 12 5ona Pubes 5�CTION XX qra e g1011 16 ' " 5�CV ON XX i C 1'6" girders I2" 50NA TU[3�5 � 6 NOUS� -7 1611 12" 50NA TTU 5 51011 50NA TUP� LAY-OUT . � y c er iSDo n e / old poA Rd L? OAD _ /V 75 .000 /9 . .47 .. E � � ,� L P�00 401,00 �+e Ulrertl e"VAS )0 0 sl de x I10100 Q � o Zo A e. {1 /5, 300 '60 40 0 �n Qj U t� 4 d o . a wl 1 5 7'stu ui • �. �I �a Via . r�c� .10 tnl o $ AC 1 . -S70 • C ts •. 2 !� $ 5 70! 09 # Y 7