HomeMy WebLinkAbout0511 OLD STAGE ROAD - Health 511 OLD STAGE RD., CENTERVILLE
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UPC 12543
No. 53LOR ��`��•co„S°`�`
HASTINGS, MN
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CO'.%1110\XVE.ALTH OF MASSACI- USETTS
_ EXECUTIVE OFFICE OF E:�'vlROtib4E\TAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE NNINTER STREET. BOSTON DLA 0210F i6174r 292.550o
TRUDY COXE
Secre•an
ARGEO PAL'•L CELLUCCI DAVID B STRI:HS
Governor Comauss oner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 511 01 d Stage Rd.. Name of ownerC onn i e. Andrews
Centervil ea MA Address of Owner: Same
Date of Inspection: 7-1- 7
Name of Inspector:(Please Print)WM. E . Robinson Sr.
1 am a DEP approved systerR inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinsoneptic Service
MaTingAddress: PG Box 0 9, Centerville . MA
Telephone Number: 7 7 8 0
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-sit7se age disposal systems. The system:
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: 4u y► Date: `3—
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 _
REr��vEO �
OCT
1 5 1999
TOWN Of S*NSTME N
HEpI.TN OEPi
revised 9/2/98 Page Iof11
i� prr"d on Recycird Papa .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION econtinued).
"ropertyAddress: 511 Old Stage Rd.. , Centerville
Jwner: Connie Andrews
Date of Inspection:
INSPECTION SUMMARY: Check (99 C,•or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S STEM 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 y s, 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 (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(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 pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A I
CERTIFICATION Icontinued)
Property Address: 511 Old, Stage Rd.. , Centerville
owner: Connie Andrews
Date of Inspection: '3,3_Q -
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
ublic health, safety and the environment.
11 YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING,IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public'water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A t'
CERTIRCATION (continued)
Property Address: 5i1 Old Stage Rd. , Centerville
Owner: Connie Andrews
Date of Inspection: y'-3—�
D. SYS FAILS:
You must in 'cate either "Yes" or "No" to each of the following:
I he a determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
date ination 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 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 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 1/2 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 S TEM FAILS:
You must Indic to either "Yes" or "No" to each of the following:
The f Ilowing criteria apply to large systems in addition to the criteria above:
The s tern 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 nd 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 or perator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the D partment for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Address: 511 Old. Stage Rd. , Centerville J.
Owner: Connie Andrews
Date of Inspection:
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.
_ 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.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b))
_ The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanc."i
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
IropertyAddress: 511 Old. Stage Rd.. , Centerville
Owner: Connie Andrews
Date of Inspection: 9_3_9 7
FLOW CONDITIONS
RESIDENTIAL: .�
Design flow: /fdg.p.d./bedroom.
Number of bedrooms (design):_,L Number of bedrooms (actual):3
Total DESIGN flow Ll J 4
Number of current residents:
Garbage grinder(yes or no): A- O
Laundry(separate system) (yes or no):k; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):
Water meter readings, if available (last two year's usage(gpd): 1998 40, 000 gal.
Sump Pump (yes or no):�� b 1997 42, 000 gal.
Last date of occupancy:
COMME IAL/INDUSTRIAL:
Type of a ablishment:
Design flo 9pd ( Based on 15.203)
Basis of de ign flow
Grease trap present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita y waste discharged to the Title 5 system: (yes or no)_
Water me er readings, if available:
Last date of occupancy:
OTHE .(Describe)
Last f occupancy:
GENERAL INFORMATION
PUMPING RECORDS and lsourc,4 of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: . gallons
Reason for pumping:
TYPE 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)
I/A 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(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or noA,
revised 9/2/96 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
"rop"Address: 511 Old. Stage Rd. , Centerville
Owner: Connie Andrews
Date of Inspection:
BUIL NG SEWER:
(Local on site plan)
Depth elow grade:_
Materi I of construction:_cast iron_40 PVC_ other(explain)
Distan a from private water supply well or suction line
Diam er
Com ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:_Yconcrete_metal_Fiberglass _Polyethylene_otherlexplain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No)
` 4.
Dimensions: e� a rU
Sludge depth:
Distance from top of sludge to bottom of outlet tee or-baffle:
Scum thickness: )—X"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom o outlet tee or baffle:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, d th of liquid level in relation to outlet invert, structural integrity,
evidence�o leakag�ef etc.) G A L— �A I► I�1/L 1/>!d G [."
GREA TRAP:
(locate n site plan)
Depth b low grade:_
Material f construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimensi ns:
Scum th ckness:
Distanc from top of scum to top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Com ants:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
eviden a of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 511 Old. Stage Rd. , Centerville
Owner: Connie Andrews
Date of Inspection: -3-Q c7-
TIC TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
Iloc a on site plan)
Dept below grade:_
Mater al of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dime ions:
Capa ty: gallons
Desig flow: gallons/day
Alar present
Alar level: Alarm in working order: Yes_ No_
Date of previous pumping:
Co ments:
(co dition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence f solids carryover, evidence of leakage into or out of box, etc.) - -
PUMP HAMBER:_
(locate n site plan)
Pumps n working order: (Yes or No)
Alarms in working order(Yes or No)
Comm nts:
(note ondition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of1I
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 511 Old. Stage Rd.. , Centerville o
Owner: Connie Andrews
Date of Inspection: 1�-3—? S
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 s il, signs of hydraulic failure 1 ve of ponding, damp soil, condition of ve etatio etc.)
o G�� ?teas d� ,Z
CES OOLS:_
(local on site plan)
Number nd configuration:
Depth-to of liquid to inlet invert:
Depth of olids layer:
)epth of s um layer:
Dimension of cesspool:
Materials o construction:
Indication groundwater:
in low (cesspool must be pumped as part of inspections
Comments
(note con tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
s�
PRIVY:
(locate o site plan) V
Materials o construction: Dimensions:
Depth of s lids:
Comments:
(note condi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
rev-Lsed Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued)
I
�ropertyAddress: 511 Old. Stage Rd. , Centerville
JWrW: Connie Andrews
Jate of Inspection: 9 cr
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)
W
J
6 D.
C-
a
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinuedl
roperty Address:511 Old. Stage Rd.. , Centerville
Owner: Connie Andrews
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
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
/
V Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
_Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how yob estab ished the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
. TOWN OF BARNSTABLE
LOCATION :I'C/ ®G 0 S 7,6-S /PAS SEWAGE # 3367
VILLAGE Q1/7-251t ASSESSOR'S MAP&LOT/`0 "��
INSTALLER'S NAME&PHONE NO. lLYy/,!,r tPO Q LAl rzo V�- 771= -7 7-6
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) ' «f C'-l� - C-A-A(size)
NO.OF BEDROOMS
BUILDER OR OWNER `
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 byd�J"
fat
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ASSESSORS MAP 14
No. �C�` �`✓ PARCEL No.—- - � 1 Fee 4 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplication for �Digpoal *pztem Cow5truction permit
Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
511 Old Stage Rd Frank Andrews
Centerville
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Sery
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder( no
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) install a 1 , 5 0 0.,g a 1 septic tank,
D-box & 4 #180 high capcity infiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi o of Heal p i
Signed L Date
Application Approved by
Application Disapproved for the following reasons
Permit No. 7 —z Date Issued ��.
� .-, , ,..r ry,.- • .�� .,? �,..'sr...,�-+..-...iy. ..ti,,;"}�--..-ia�'` w..�....,-�-��.:�'�.+.. .d"-<�w� ^•�,,,`•r ...d•-w^,}'T` iw ..t . .... . .r" '' ...•+-'�.^�,... ^i
No. �,7 Fee 4 0.0 0
,j �
'THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zppftcatton for Mt!5pool *pgtem Congtructton permit
Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
511 Old Stage Rd Frank Andrews
Centerville
Installer's Name A dress,and Tel.No. Designer's Name,Address and Tel.No.
W.E. RoM son Septic Sery
P.O. Box 1089 }
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder( no
Other Type of Building No.of Persons Showers( ) Cafeteria( )
r-
Other Fixtures
-- 1
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date N
Title
sand
Description of Soil
i
f
Nature of Repairs or Iterations(Answer when applicable)) install a 1 ,500 gal septic tank$
D-box & 4 t,180 high capcity--infi trators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
F in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' o Qf Hea
Signed 1 Date
Application Approved by
Application Disapproved for the following reasons
r
Permit No. % °' -y Date Issued._
THE COMMONWEALTH OF MASSACHUSETTS,
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
G Certificate of Compliance - -
THIS IS TO CERTIFY,that the On-site Sewa a Dis osal System installed( )or repaired/replaced( X)on
by W.E. Robinson septic FerviC%r Frank Andrews
as 5 d5tageRd Centervill—e . has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated .4 —�—
Use of this system is conditioned on compliance with the provisio et forth below:
.�'• r.,
No. �,� Fee 40. 00
Andrews THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wtgpogat *pgtem Congtructton Permit
Permission is hereby granted to W.E. Robinson Septic Service
to construct( )repair( X)an On-site Sewage System located at 511 Old Stage )Rd I Centerville
and as described in the above Application for Disposal System Construction Permit.The applicant reco nizes his/her duty to
comply with Title 5 and the following local provisions or special condidQns.
All construction must be completed within two years of the date below.
Date: ��r`'Z 4r' !�_� Approved b
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
CV-j2 5/2, hereby certify that the application for disposal works
construction permit signed by me dated / �' 9� , concerning the
property located at 5;N q - meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase inflow and/or change in use proposed
• There are no variances requested or needed.
�I
SIGNED
DATE: ,
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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