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Home My WebLink About0093 PRINCE HINCKLEY ROAD - Health 93 PRINCE HINCLEY RD. CENTERVILLE A= 172 183 LO ION SEWAGE PERMIT 0. Lot 2 Pr c 8,480 VILLAGE Cent _ryi 1 1 ., MA. IN�STA LLER'S NAME i ADDRESS Alfred Fuller West Barnstable Rd. Marstons Mills, MA. BUILDER OR OWNER Alan E. Small, Inc. Box 531, C pntarvi l l p. MA. D A T E PERMIT ISSUED 8/30/78 DAT E COMPLIANCE ISSUED � l `7� r y� %�� bb _� THE COMMONWEALTH OF MASSACHUSETTS BOARD Of Application is hereby'made for a Permit to Construct or Repair an Individual Sewage isposal Lisposal Type of Building Size Lot__/.��,,/ ---Sq. feet P4 Other--fixtures Percolation Test Results Performed by---�P_,& ISIV ---minutes per inc b ------------------- ----```--``-----------'``-----------``------------- ------'---`-----````----`------'------`````�-----'----------``-- -`��----- Agrrvnn,ot: The undersigned agrees to install the afore6escribed Individual S'e�vage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersiffd further agrees not to place the system in operation until a Certificate of Compliance'has bee i s d by �"of health. 2--__ ate . � ~ Date Application Disapproved for the following reasons:......---_—'_------------------------------------------------------------------------------------ _----_---_'.-_--__--._—.—_._--_-_-.'------__------_._--____------._—.------ ""� / Permit No......................................................... ' Issued--..�.�'��/_'�1}--.-__-_-- Dat e '' ' f 7. a 1° No ........ Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS x BOARD O HEALTH , AVV iratiun -fur ENrupwia Wvfkii Cnowntrurtiou Prornift a Appltcation:ts hereby'madetfor a. Permit to Construct:':( )' or Repair ( } an Individual Sewage isposal System at r " �Location'4Address //' or-Lot'Nof ------- `--- :s- ................................. ........ ��..... ....................................................t Address �( t i C(C /' _. r�xC�s +.' " /� f✓t/"" .. . f. a' A ... W 1- his ler d Type of Building Size ---Sq. feet Dwelling—No. of Bedrooms._... ...., {� ---...-.- Expansion Attic ( ) Garbage Grinder (/L)'U aOther—Type of Building --------------- ---------- No of pens'oils...--_...__-.-------._.... Showers ( ) — Cafeteria a' Other futures W --------------------- --- - ----- I `_.!� :±r' ��..))g gallons per person per clay. Total daily flow-:_.:_--- ---- ..._-----------gallons. o; Septic ":rt lv Liquid capacity. li __..gallons Length........... ... Widthi............... Diameter .. Depth......-__--- Disposal Trench' No ..... .............. Width -. `-.: Total Length _----/------_ Total leaching area " sq.ft. Seepage 1'it No. _/............. Diameter.........F:..... Depth belo� inlet _-.-1,;-...... Total leaching area---?Z ----sq. ft. Z Other Di4tribution box ( ) Dosing,�anlc '-' Percolation Test Results Performed by..-.,� �_--- --�s' .�- --•------------ Date-----7.JV--- 7P- ".rest Pit No. L._�,2._.-nnnutes per inch Depth of .Test Pit_------------------ Depth to ground water (s Test Pit No 2 ±'_.._..__.'_minuiesper inchr_A'Depth of Test"'Pit.:....:........... Depth to round water.. _._..-.. -.--. -- J � D Descriptton of Soil ¢ i q. l r ��--/�BC(---Gtst� x . W ----- --- UNature of Re ties or Alterations—Answer;when applicable ---. .::._ ----- _-------------- ------------------------ - ------- ...`--..... . ..... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code The undersib Ie<l further agrees not to place the system iii operation until a Certificate of Compliance`has been issued by the boar,,of health.ir, s �'77�_ -1151-7 ---------------------------------;--------- Application Approved B t Date fDate Application Disapproved for the following reasons: =--- -- -•---- ---- ----- -----------------------------••------------- � v �f /-)Date.. PermitNo.......................................................... Issued--' -- '-•_....-• -------•---................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD . OF• HEALTH .......OF..... " Z ................................. �rrttf it tr v anip taurr THI1j^1LZ11 O That the Individual Sewage Disposal System constructed or Repaired ( ) by....... .............. . ............ :. -- ----- ................... --- / fa Instiller at' - ----------------------------- has been installed in accordance with the proves of 1r c I of The State Sanitary Coe as des 'I d in the L application for Disposal Works Construction Permit ivo.- •:_ --7T .....:.-: dated ....: 1- ....7�L'.................. THE 1SSUA.NCE;,OF TH!S,.CERTIFICATE SHALL NOT BE COW RUE® AS A GUARANTEE THAT THE SYSTEM WlII PUNCTION' SATISFACTORY / ------- ----- -•-- Ispctor---•-- _ -----DATE 1 THE COMMONWEALTH OF MASSACHUSETTS ,rBOARD OF,IEALTH 7 ,/ ... . OF. .- .................................. �.. No. 7 .._ (` > al rk_ �arti �t ' rrtit i� Permission is reby granted.- -- ---- 1 ; to Constr ct (' or Rep ( . ividual Sew Disposal S em at No.:. t4 --- - -- • -•-•--- Str as shown on the application for Disposal Works Construction P •No:.... .,-. tec--..,F .a'.�.- .-....__. :. .. �'��L..fit_ ----- ---------- :-,E� \ P f� `� Board of Health DATF, ----------------------------------------------------------- FORM " r' 1255 HOBBS & WARREN-''I.NC.. PUBLISHERS :I\, L ::'..a .... n•J � _,,.�% .. r�-'"t:.c z-�. .,k ... ..., .�.�_�.,.-a., SsC• .�..vf,.. _. �._ w.. w.�. _ ...z ►...to Gasrs�o.�t✓ �tzi+.tt��sz. _ 2�+t�� F t.�w = i t O � 3 t 3�c� G•e�•17- `�� j-•.�,I'SPQSAd_ PIT • USE. lOoc� �� i5�� QOLWfit �A+InOsGrAs. h �•+ i��I 1�a. -� - LL lc:X:;> SF 14 Z.5• s ^ S'75 So gam. t •c> - l v S.Pp. p ToTQL pESIGtJ = 42S &.PD. C1 43 ToTat.. t�at�*f FLow = 33o �5:P.D. � to l� t%'EfLGDItITiDt...t �'l�TE l��tu 2.Mi►J 02 LESS. F �9f� .o` MC HARD BAXTER , : fJ4-AGE Per4-C46 IIIAoL- � /I/Z2/7.7 ° `$� S Tor �►+e s�aca.a "-4 4 P. . a1,7 4'Pa 1w 6p.L. %7 'lgox 9G sepnci INV, mod wvl act I aoo qs� �.�v. uwv, (,raa✓. C'A L.. 9G a 4G 2 l..sAcw , PIT V4I rw was++et> Also Sit c�af� f L OCAT'I U fib.. t ( eer ,vl LLS ( C uwr t F wr Tj4 A r TI-A G- k"�L71JT9t5j-tal� St�O,��W Pt..a.t-J Rr F•�:t~ L:d�.G 1•tC t:r �.l Gcatil,t�t.�(5 W I Tk TWZ: 51 DE t..t►-�E- t -Tow►. r— d �k r c.c- I t�t t�:� ► at t..l tZGGlS'J�ttCD 1..A1.tG 5U2Vi=y'i�t ,�, T c_AN is ►.JOT 1 �.�,t_t7 Una Ar.t o �Cevt�_tG. v ItrtAS�,� k TtAi± APR t-1 C_b.tiJT U•.G.cl i_U I�r_1'i=ti~Mti W >rc%� Lt i t •� - � .— existing double window unit DW � �j BATH PORCH 4'x 9' 14'X 11'6" KITCHEN 00 DINING P 00 BATH MASTER BDRM 10'x11'6" 11'x 11'6" Tx 7' 0 14'x 11'6" 25'x 14' GARAGE n ro e is m F———— 13'X 19' BEDROOM OFFICE LIVING ROOM 1 10'x 12' 0'X 12' L rL L h 93 PRINCE HINCKLEY Drawings by,Jim Upton 508 362-4440 Z Pam T ' i ` S1 156 1 '� COMMONWEALTH OF MASSACHUSETTSL - 3 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r• � gat s,. 4 fr'4 1 { t, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSy SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM �� " : PART A r CERTIFICATIO_N ,1 E Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 � Owner's Name: JAY BUTLER C/O LAND AND SEA REALTY - - Owner's Address: 8 WEST BAY RD.OSTERVILLE MA.02655 Date of Inspection: 10/29/01 LREE ,1 Name of Inspector: (please print) JOHN GRACI a- Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536F1• p;r :. Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT �tK 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 m training and ` p P P p y g " K A 3�r experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' X Passes _ Conditionally P s } y Needs Furthe luation by the Local Approving Authority :•• r }, Fails ` �,, Date: 10/29/01 Inspector's Signature: � The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within j 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 taV4 sent to the system owner and copies sent to�the buyer,if applicable,and the approving authority. tom ' Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE a, SYSTEMS USEFULL LIFE. y ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This K inspection does not address how the system will perform in the future under the same or different conditions of use: , -; is Title S Tncnrrtinn Fnrnn 6/15/MM Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ` Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 a; Owner: JAY BUTLER C/O LAND AND SEA REALTY r Date of Inspection: 10/29/01 " Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X informationhih indicatesthat any of the failure criteria described in 310 CMR 15.303 or in 310 i I have not found any which CMR 15.304 exist.Any failure criteria not evaluated are indicated below. a � Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. µ 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. ; a Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. ; n/a 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. 1;� # � with a complying septic tank as approved by the Board of Health. ` '" sound,not leaking and if a Certificate of Compliance*A metal septic tank will pass inspection if it is structurally liance indicating ° p that the tank is less than 20 years old is available. r ND explain: n/a �X ' n/a Observation of sewage backup or breakout 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): y . _ broken pipe(s)are replaced 'i� �" _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a � n/a The system required pumping more than 4'times a year due to broken or obstructed pipe(s).The system will pass Y Q inspection if(with approval of the Board of Health): ; gym; _broken pipe(s)are replaced s _obstruction is removed ND explain:n/a 5 MO•: ,; > , Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = ,a PART A > CERTIFICATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 4 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 St 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 L 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 f 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 Y. '! 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 R. supply or tributary to a surface water supply. g _ The system has a septic tank and SAS and the SAS is within a Zone 1 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and 3 volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia P. nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy �` i� Vic?' of the analysis must be attached to this form. f, 3. Other: n/a ' e .W i' -k �'A,.. iy a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS •* . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 �' = D. System Failure Criteria applicable•to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: f Yes No 4 _ 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 'h day flow ` X Required pumping more than 4 times in the last year N-O due to clogged or obstructed pipe(s).Number of times pumped nLa. T. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X An portion of cesspool or ri is within 100 feet of a surface water supply or tributary to a surface water su 1 Y P P privy. pp Y ry pP Y 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 DEPti.. certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free x Y` from pollution from thatfacility 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.] _ (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 4; `dY ` i �1 r 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 t X the system is within 400 feet of a surface drinking water supply '� y �:y v _ X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water'SUP ply well " r a° y If you have answered"yes"to any question in Section E the system is considered a significant threat,or answeredo N "yes" in Section D above the large system lias'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 F should contact the appropriate regional office of the Department. t. d M Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS t;r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No >'`C X _ Pumping information was provided by the owner,occupant,or Board of Health ,a 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? . 4 X Have large volumes of`watdbeen 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? + ` of :� X _ Were all system components,excluding the SAS,located on site? - 1 X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the k w, 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 °.' ,q 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 t X _ Existing information.For example,a plan at the Board of Health. 15 X _ Determined in the field�if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] a: ,. ;,. o a; 1f? c Page 6 of 11 ;k OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C g SYSTEM INFORMATION Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY r Date of Inspection: 10/29/01 ok.. iY 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: 0 Does residence have a garbage grinder(yes or no):NOr f:z ` Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] :: : Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO 1 Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 7/1/01 t ' r r COMMERCIALIINDUSTRIAL Y� a Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpdY 'v, Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no):NO , Industrial waste holding tank present(yes or no NO f" Non-sanitary waste discharged to the Title 5 system(yes or no):NO t Water meter readings,if available:n/a Last date of occupancy/use: n/a `y OTHER(describe): n/a GENERAL INFORMATION Pumping Records t Source of information: n/a ` Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--H'ow was quantity pumped determined?n/a : Reason for pumping: n/a TYPE OF SYSTEM # X Septic tank,distribution box,soil absorption system ` ;s _Single cesspool ' _Overflow cesspool . ` _Privy '4 _Shared system(yes or no)(if yes,attach previous inspection records,if any) h _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from 7 X system owner) Tight tank Attach a copy of the DEP approval ` a Other(describe): n/a �'" + Approximate age of all components ';date.installed(if known)and source of information: Y 1978 Were sewage odors detected when arriving at the site(yes or no): NO tr 1 ' Rage 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART C 4. SYSTEM INFORMATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 ` Owner: JAY BUTLER C/O LAND AND SEA REALTY ''` Date of Inspection: 10/29/01 BUILDING SEWER(locate on site plan) -: Depth below grade: 18" ' Materials of construction:_cast iron =40 PVC Xother(explain):20 PVC ' p Distance from private water supply well or suction line: n/a "Y Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER .R" r SEPTIC TANK: X(locate on site plan) Depth below grade: 12" ;. Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is=age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions: 1000G L 81611 H 51011-W 4' 10"" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" a 'k Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: n/a c How were dimensions determined:MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): t THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S ' ` USEFUL LIFE , x GREASE TRAP:_(locate on site plan) Depth below grade: n/a . Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a ' Scum thickness: n/a w = o Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a ''� r` Date of last pumping: n/a r, Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related n , ; to outlet invert,evidence of leakage,etc.): n/a 1> , � W F_t� Page 8 of 11 a V OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 .;J ':: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a k Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a k Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day $ Alarm present(yes or no): N/A "- Alarm level:N/A Alarm in working order(yes or no): NO r "' Date of last pumping: n/a Comments condition of alarm and float switches,etc. : n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into ; r or out of box,etc.): Ix- r BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NOilk Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a r: .0 -j'; � rn ' h R • Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E,'F PART C SYSTEM INFORMATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) ' If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a "l n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a 5 n/a 3': innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,sign$-of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.THERE ARE NO SIGNS OF FAILURE AT TIME OF INSPECTION.PIT WAS EMPTY AT TIME OF INSPECTION.BOTTOM AT 9' r CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a 1 Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO 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: n/a Dimensions: n/a Depth of solids: n/a (' Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ' n/a .z r N,: Q Rage 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F" PART C SYSTEM INFORMATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 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. y'+ IA ; � 9 k a 9: A a� H A µµAARR } A ffnn�� AO11) f . 4 b� ,q : k.✓Y d S k 'q i in ' Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 93 PRINCE HINKLY RD CENTERVILLE,MA 02632 L92 Owner: JAY BUTLER C/O LAND AND SEA REALTY Date of Inspection: 10/29/01 SITE EXAM _Slope _Surface water _Check cellar a ` Shallow wells ' Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED BY AUGER-NO WATER AT 12'-BOTTOM AT 9' i s VIC �P - I1