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HomeMy WebLinkAbout0110 PRINCE HINCKLEY ROAD - Health 110°Prince Hinckley'°Road�: _ j Centerville184 A= 172 — s. 7 Commonwealth of Massachusetts y p., Title 5.. Official Inspection Form le Subsurface Sewage Disposal System Form-Not for 9 p Y Voluntary Assessments f ' 110 Prince Hinckley Rd. ;10 Property Address ,�I James Cleland `0 Owner Owner's Name Lr information is C required for every Centerville ✓ MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection "I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please.see completeness checklist at the end of the form. Important:When fillip out f A. Inspector Information S* 13SEoti on the computer, use only the tab Paul C. Martin key to move your Name of Inspector cursor-do not Cape Cod Septic Services Inc. use the return Company Name key. 350 Main St. Company Address West Yarmouth MA 02673 City/Town State Zip Code x fsmm 508-775-2825 SI5016 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/14/2019 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts lip Title 5 Official Inspection Form <li Subsurface Sewage Disposal System:Form-Not for Voluntary Assessments � 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or and all of and 6. 1) System Passes: ® 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: System in working condition. 2) 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. Check the box for es", "y no' or not determined (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts IR Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: l5insp.doc•rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name required for is every Centerville required MA 02632 1/9l2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 5.0 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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 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: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form f IQ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® AnY portion of a cesspool or priv y is within a Zone 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] 11 ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA, 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 l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts y2 ----, Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Prince Hinckley.Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The. owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ 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? ® ❑ 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: ® ❑ 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(5)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 6 of 18, ., Commonwealth of Massachusetts _,PTitle 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. Clty/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3 330gpd Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? El Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2016=315gpd 2017=195gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑. Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined?. Reason for pumping: t5insp.doc•rev.V26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <lo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank..Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1977 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 25" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts —, Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate). ❑ Yes ❑ No Dimensions: 1000Gal Sludge depth: 8-10" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1-2" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank. Tank is in good condition. PVC tees in place. Tank at normal operating level..No evidence of tank being overfull. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 10 of 18 I Commonwealth of Massachusetts —IF Title 5 Official Inspection Form ' Fig Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,• 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 y ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' r io . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 110 Prince H inck!ey Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville MA 02632 1/9/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required)..Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate.on site plan): 011 . 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.): Box was inspected with sewer camera. Box was in good condition with effluent at outlet invert. No sign of overloading or hydraulic failure. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12'of 18 i Commonwealth of Massachusetts =,`1P Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No*. Comments (note condition of pump chamber, condition of pumps and appurtenances; etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If.SAS not located, explain why: Under reinforced concrete pool patio. Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville _ MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-Leach pit per BOH records. Pit is under pool patio and could not be inspected. 12. 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '• �" 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is Centerville required for every MA 02632 1/9/2019 page. cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): Mnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 15 of 18 Commonwealth of Massachusetts —,p Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name information is required for every Centerville MA 02632 . 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f Commonwealth of Massachusetts 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 110 Prince Hinckley Rd. Property Address James Cleland Owner. Owner's Name information is required for every Centerville MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +10' . feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® 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: Site is in a known area to have no groundwater issues. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18 Commonwealth of Massachusetts :.= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 110 Prince Hinckley Rd. Property Address James Cleland Owner Owner's Name required for is every Centerville required for eve MA 02632 1/9/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary; 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I + COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION wr t S� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owners Name: Owner's Address: X =' -T ca Date of Inspection:2/28/07 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.O Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 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: 2/28/07 The system inspector shall subm/acopy of this inspection 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. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection: 2/28/07 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 winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM APPEARS TO MEET MIN]MUM PASSING REQUMNIENTS. OPENED PIT IT WAS HALF FULL STAIN LINE ABOUT 18"FROM INLET PIPE B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' 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 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 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection: 2/28/07 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: 110 PRINCE HINCKLEY RD CENTERVII LE Owner's Name: Owner's Address: Date of Inspection:2/28/07 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 _ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 3 10 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered yes''m 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 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner: Date of Inspection: 2/28/07 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? — _ 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 Existing information. For example, a plan at the Board of Health. X _ 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection. 2/28/07 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): N DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NA Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): _ 05-- /®O G'►PQ Water meter readings,if available(last 2 years usage(gpd)): 38�i G Sump pump (yes or no): NO Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Was system pumped as part of the inspection(yes or 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 contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: 1977 AL FULLER OFF AS BUILT CARD#77-498 Were sewage odors detected when arriving at the site (yes or no)? 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: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection: 2/28/07 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:_ (locate on site plan) Depth below grade: 12" 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: 1000GAL TANK Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TIME,BUT DOES SHOW SOME SIGNS OF CORROSION. 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: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection:2/28/07 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: NA (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.): 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.): Page 9 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 110 PRINCE HINCKLEY RD CENTERVII.LE Owner's Name: Owner's Address: Date of Inspection: 2/28/07 SOIL ABSORPTION SYSTEM(SAS): —(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: 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.): PIT IS ABOUT HALF FULL AT THIS TMffi STAIN LINE AT 18"FROM INLET PIPE. 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.): w Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection: 2/28/07 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. 34 AN `mac.C V r Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM J INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 110 PRINCE HINCKLEY RD CENTERVILLE Owner's Name: Owner's Address: Date of Inspection:2/28/07 SITE EXAM Slope: Surface water: Check cellar: Shallow wells ` Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: L kl LOCATION SEWAGE PERMIT NO. Lot 125 Prince Hinckley Rd. 77-498 VILLAGE Centerville, IMA. 02632 INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER Alan E. Small., Inc. ,Builder, Boy 53L rp-?l F'Pryi l l a- ,MA • 02632 DATE PERMIT ISSUED August 17, 1977 DAT E COMPLIANCE ISSUED September , 1977 �5 No....... .. Flas................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,� tirtttiun Inr Uiipla iat Workii Tonfitrnrnhin Vrrntit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----- --- ----�----------- --- -- --�h .. ..-�--............ ----- �-----• Location•Ad or-- t r Installer Address PQ �,i Type of Building Size Lot.... S/_4e ---Sq. feet Dwelling—No. of Bedrooms_-______3-------------- ---------------Expansion Attic ( ) Garbage Grinder (1;'q a4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q, Other fixtures ----- -------------------------- - W Design Flow..............`___ -----------------------gallons per person per day. Total daily flow........ .?�_t�____------_--...--------gallons. WSeptic Tank!Liquid capacityfD6 -_gallons Length---------------- Width................ Diameter...____.._._.._ Depth................ x Disposal Trench—No. .................... Width....... 5X... Total Length-------_------:-__._ Total leaching area--------------------sq. ft. Seepage Pit No......I........... Diameter.Y ------- Depth below inlet.................... Total leaching area-------.----------sq. ft. Z Other Distribution box (X) Dosing tank ( ) `-' Percolation Test Results Performed by._.. '�� _ _.__.._. ----------- '__..`!.!'"'Date.... .. --- ---- ... a Test Pit No. 1----------------minutes per inch Depth of'Test Pit-------------------- Depth to ground water..-----.------..-..____- f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ -------------------- ---------------------- ...-•7- xDescription of Soil----=�--� `� U .....................6---------------------------- -- ......... -------------------------------------------------------- -_---------------------_----.-------------- W UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------_--_.----..--_--- -----------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------- Agreement:. The undersigned agrees to install the aforedescribed.Individual 7ed age Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The under si further agrees not to p e the system in operation until a Certificate of Compliance has bee s ed by t o of heallky Sign '� Date 7 Application Approved B -Slr_____ _ _______ _.9.-- PP PP Y � � -. �./_ IIate Application Disapproved for the following reasons:-----•---------------------------------------------------------------'------------------------------------------ ------------•---•--•------•---------------------------------•---------------------------------------•----...-------------•-------------------------------------------------------------...--------•---•-- Date Permit No......................................................... Issued....J-D -'3- 7 7 Date yam;;: '^ fir; ,.,,; ..,,. t;-r,-+.+r^--'^'ee *+�r -?,.� .^mc r*f Y!`+�- .7 'I ff7l" " "�'�`""a"'^e�p"° „€. NoFEE.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O .����tttt i#111 -fur ��iqua-a1 �rk� Totmirurtiall Punift ApplicatiokJ9 here'by'made for a Permitto Construct ( ) or Repair ( ) an Individual Sewage Disposal ern a ti ' t C� ll .�,L,� ,fib/ cam'/,� } �.,rr Location A,ddddress ,r or Lotf No. ........................................t/. ..C� tfa!��...C..•+.� -___..-,_ ___ ___________________ f v . Owner Ad�dress • Installer Address UType of Building Size Lot.---'.. ---Sq. feet Dwelling—No. of Bedrooms._-__ _--___-------------Expansion Attic ( ) Garbage Grinder ( ) p14 Other Type of Building ------ ------ No. of persons- ---------------------- Showers ( ) — Cafeteria ( ) Cal Other fixtures W Design Flow-.._.-____..______ gallons per pcl son per day Total daily flow ....... ..___________----:._- -gallons. septic T-Malik—Liquid cap tclty gallons Length----------------- NVulth----- ------ Diameter--.--.---------- Depth------------- x 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 (x) Dosing tank ( ) '-' Percolation Test Results Performed by:"• -- -- "----- ----- ---- ---------._ Date---------------------------------------- Test.Pit No. 1----------------minutes per inch Depth of "lest Pit.------------------..'Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of 'Pest•I'it-------:-________,__ Depth'to ground"water-_-_-..____-_-___- . Description of SoI� -` s - '� �. La� T � - - G- ---- �- ------ ---- ----- -- •----------- ----- -- ---- ---------------------------------- VNature 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 Article \I of.the State Sanitary.Code—' The undersign d further agrees not to place the system in operation until a Cerfificate,,of`Compliance has bee/n'i'ssued.I the*boardlof healthy /f. _�� � ` '� �. Gy' f to r .. rSlgne - - •- -------------------------------- Date Application Approved BY _ ��' r jf/p/� $. ' f 9-7 y r . ate Application Disapproved for the following reasons:.............................. ---- __,__,_ _:------ ------. - --------- .., ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- r Date Peri,iit No......................................................... r Issued................................................. Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD F H EA'LT:H ,a 7. O F. Tertifirab a THI O �T That the Indlvidual Sewage Disposal System constructed ( or Repaired b. _ --- - - -- --------------------•' - --- •-------- p .. �. .da• +.x � nsta r at. ..._.. ` ' has been installed m accordance with the provtstons of \r e XI of r he State Sanitary C�ycleras described in the application for Dis�posal,Works Construction Permit-No..-.- ? � __ _ dated Q':_ _,�7:=_--7 7. ......... «e e :r THE ISi' APedEl-OF THIS°CERTIFlCAT:E SHALL"NOT,BE CONSTRUED AS A GUARANTEE THAT THE SYSTEIW V"I`LL,.FUNCTION SATISFACTORY: :. DATE...............................................................:=--------•---_..__. Inspector r i:- A. THE-COMMONWEALTH OF MASSACHUSETTS ,.. BOARD O KEALTH' ., . 3 .... "--- No._ ;° F� FEE_. i g tt� xk a truldboil frrmit 4 Permtssi( is"Vreb 1 malted -- Yg to at NonStru or Re�alr )"m In rvu Sewage; y al System • i-- _n ,jLL[L as shown on the application for Disposal Works Construction`s •ernrit N012..__.-: Da __..6'- --- ��__.-._ II Board of Health7---------------- - - DATE`.- f - ------- ------- - --------- FORM 12555 HOBSS & WARREN:. INC.. PUBLISHERS , y"a•" ,ask. x,:rru,_... ..,.. ... �. ,. _. ,.. .+<s_a.i4►�•a ..�,n+�:i:eww.�: � v r 37S G�c8 G N 1�T�/t fJ>t� Y FIGI✓ 330 i'I leo/ ,ax<Ac 10,Ago rAram' I�ul1Et, GAp 70 .s,4tio y -1I�3 T e,-o4ucl- 9,g,1,6 92.0 HEp�v,rt SAND T/C 7AA-kk i ,c�rr-9o.p G XG 46AC Iq7 F 'TlFI>~DLC>J C�1� LL 1., 0 ATE -7, ZC,•� 1 C r-iZ T t 1^Y T"A T- T N C.. Ko? Dw cu,. 5 -law kj PL A ti`t �EQ C L5a`1 GCW',PLVG W i TN 'p't—Et= �1[a'E Li►�t� ,atiJ� ''E"1 "ACK V QU14ZGIV&►.rTS ot` Tla� ! 'To W v o�= , tU`s'1� l.� . , 1 1�r..A U CZEGtSc�ZiVD t_,A,►rtp SU��d�Yotz.S THIS 17LAw IS 1t.15!'LtJ.f.�EtJ�" 'Suzvr--' �- TtaL— G��� �;, CS SllGiUlLti kk.;4 FlC USGQ Ta L�CTGCMt wli= l UT Li t�t��; �PpLt G�.►-.��' Q�.�> I . AsBuilt Page 1 of 2 LOCATION �E SEWAGE PERMIT . N0. Lot 125 Prinoe H�nc}clev Rd. 77-498 VILLAGE Centerville, MA. 02632 INSTALLER'S NAME. & ADDRESS i B U I'L D E R OR OWNER Alan E. Small, Ino.,Builder Anv < ("Pyli-Ay►i I I P� a. o26 2. DATE PERMIT ISSUED 77 DAY COMPLIANCE ISSUED Se]*embers 1977 i { s http://issgl2/intranet/propdata/prebuilt.aspx?mappai=172184&seq=1 11/6/2018 i h?.-�.,o..�--�-� iL0 -C"AT10N SEWAGE PERMIT NO. sS4/ t VILLAGE a) t -f^St M i! 5 �INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED 14 Imo- I DAT E COMPLIANCE ISSUED -- o 77 i A=- 0 . / eA. ........... je5 �e C4+1YCOMMGNWEAy.TH OF MASSACHUSETTS //BOARD F HEAL.JH To"��''._.-...--------OF..... . .......................... .. ------- .....--....----- t -for Ui.ivoottt Works Tomitrurtioo Vrrotit ApplicaAio!4freAba y'made for"a P`er�mi-t'�0 onnstruct ( ) or Repai an dividual Sewage Disposal ystem ocationc ddress0. ...... ................................ .............. P/-./ . ......•.. ... ......... • •-----••------ Ow = i / ^^J Installer Address ype of Building Size Lot_. . C .___Sq. feet Dwelling—No. of Bedrooms--._-.-_�..........................Expansion Attic ( ) Garbage Grinder (AIP Other—Type of Building -__------------------------ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixturfs ........ ---------------------- ------------------.._..-----.. ----------- ---------- esign Flow.. _ 'i �..............gallons per person per day. Total daily flow__--______. ........ ._..gallons. g P P P Y Y eptic Tank—Liquid capacity I ......gallons Length---------------- Width................ Diameter................ Depth....-_----.----. Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area...............-----sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth belowLLinlet..................._ Total leaching area---_-._---.--___-sq. ft. Other Distribution box ( ) Dosing tk ( �j�9f— �'�� 7 7 Percolation Test Results Performed by.........x'._ l�` � �___ Datel.J. '..7, _..._-.-_.-_-. Test Pit No. 1.... -----minutes per inch Dept of Test Pit____ _______________ Depth to ground water...---.--_-.-----.-_.-- Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--.-..--._------..._. Q+' ---------••• ..... Description of Soil------ -- if �� � r/` ��G� .--... x -..s 4 `------• Gd�r-� :-•--------------------------------------------•----------------------------------------------- ... U ' W --•-•-----------------------•--- --------------------••-•--------------------.------•-----••-•-•---------------------------------•----------•-----------•----.--------------------------------•-•------ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------............ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual ewage Disposal System in accordance with Z(U he provisions of Article XI of the State Sanitary Code—The undersi ned further agrees not top ce the system in Operation until a Certificate of Compliance has bee s ed by t oar of health. � .­)Signed ..... '..... .. ...•--_.. --•-•-•---.......... •- --- --------f-----------, - A licatiori Approved B "•' � l/f/ Date Application Disapproved for the following reasons:----••------------•-----••-•---------•-•-------------------------------------------•---.------------•--•- ••---- f -----------------------------------------•- ---------- -----------•-:._�_._...... �/ X( .- 7 Permit No. Issued --.:_:_--.. -------------------Date---•--. Date .., P`-. '�• r �. 's �:r"."•_' _ :"a�M -m^�:. a?,z*x• .^. .e+�.-�.t s•rt Lr71 No. .. ,. . Fins........./... ............ THE COMMONWEALTK OF,MASSACH;USETTS 4e9. BOARD` OF HEALTH €€€ OF.. 'I Z I ra Tait f ur D 1q agA iark�. Cn tt r `� It Application`'is hereby made for a Permit onstruct (�o,J or' Repair (1 ) an Individual Sewage Disposal t 1 2J System at � .. /1 11 __ _ .._ Location-Address or Lot No (' ' ---- .............�........ ...�......���.-�...... AMA �G .- _lr__`ram.............................................................. .. ..•,r _ Address W / r owner �•---- / / /_.+mot ts-�d .,cs•-- z - `------- ----.......................................................... ------ ------- - - - ------- t Installer Address Us' Type of Building -fi Size Lot... � - -,--Sq. feet ti Dwelling—No. of Bedrooms--------- --------- --- -- Expansion Attic ( ) Garbage Grinder (Al)' Other.—Type of Building _--.-'-.-... .'Showers,( Cafeteria A., YP g i`o of pt_tsuii5 ----(---- ) ( ) ` a Other fixtures t Design Flow:_ v_ ' '' - -.-------gallons per person pc r day. Total daily flow .......................� ...gallons t 9` Septic Liquid rivacltv��-Tank— q -- --gallons Length=------ - N'1�idth Diameter-------..- ---- Depth----- 4 ;Disposal, Trench—No.•....................- •-------. gth -------- ------ -- Total leaching area-----------------. .sq. ft. Width Total Len Seepage Pit No- -------- - --- ------ pth belcnv inlet-------------------- Total leaching area---: _--------sq. tt. - Diameter ---- De p Z, Other Distribution box ( ) Dosing t lc ( �" r d /B 7'7` '-' Percolation Test Results Performed b ' i Date - ���''- 7• y � 9 Test P No. L._- --_----minutes per inch Depth of Test 1 it ----.---�- Depth to ground water ----------------- it - f? Test Pit No. 2------- ------minutes per inch Depth of. Test .Pit- ------------- Depth to ground water--.------------------ . -- ---ov - rf - Description of Soil Q '--,'���` !Y ,� y£ � .�� ag : y ` ifr Era W � 4 �' t V +3 "^ ,i ---- - - W •-- ------ - -- ----. --- $; ----- ............:............................................. ----- - ` U Nature of Repairs or Alterations—Answer when applicable --- ._` 2. - r --- -- --- - -- - ------- - -•-- - ----- •-- -- �r Agreement The,uriderstgned agrees-eo'mstallt,the aforedescribed' Individual 'Sewage Disposal System in accordance with the provisions of Article XI of the State..Sanitary Code The iiiiderst led furthaer.,agrees not:to p11ce the system in operation until'a,Certificate of'�Compliance has beeneissued'by the board of health. Signed. .-------- ------ ---------• -•------ •• -•----- - - • -- -------------- Date_ `. A lication A °roved B ----- ----: -: -. ------------------------------------- Date! F PP PP Y )) Application Disapproved;for.�he folloiewang reasons:'- -- -------- --'-- - - --- --- ---- --------- ----- ----- ------ ;: • �L/ •'\�~•' Date Permit No --:-' -------- -------------•------ -- - Issued-- -••--•-- -, ..� ..., .. ,. � Date - "'*�"TH'E COMMONWEALTH,OF`_MASSACHUSETTS ' s BOARD 0 ALTH r ........OF...... Trr#ifiratr nf. f�nutItrcrr; THIS ,�O �1�F That the Individual Sew ige D spal System constructed• (- r Repaired ...X S..' I. ..... --------------------------------------------- -------- ............ has been uistalled m accordance with the prov> ions of , e XI of The State Sanitary C le a5 desctabed in the PP P Permit I�o ' _ � �^�� dated % �'- 7;- application for Dis osal'Works Construction THE ISyUAF10E•':OF TFIIS CERT4F;;CATE 'SHALLS NOT. BEsCONSTRUED AS,A GUARANTEE THAT THE SYSTEM, WILL FUP9CTION-SATIS-FACT®RY x�w DAT1 _, - t icy / .............��!�__•- Inspector fir; f l 0 a f' THE COMMONWEALTH:OF MAS�SACHUSETTS z Ix BOARD .O HEALTH a 7� t ; 1. �,/ OF No. -�+�f FEE . a •4` � � i� ntt1 kV7� aPernitsston'-teby gr tnted 4 -- �� _ yam•, ue dui. ,:rx 4 <' to Cons ctt 1-:" orb l airy IndividuewDis�p� lS;ys ' •-- --- /i a o� at No e Ct 1 _ _._ _� ,- yt e z ,�� "r" =•.'c 3 t'rreet '� s e ass hown on the application for Disposal Worts Construction Per o.: -- _-_;:- d......1-��......................... T g4 1 Y4 •dr oard•of Health 7- ,..,.� DATE__.:_I--..., Z-. S• FORM 1255 HOBSS•& WARREN: INC.. PUBLISHERS �t la. �... . ,3, _.__ew. �/ .fi�]L�F'L•��maf�a:'�EL� a.�Ysa_ic. ,._ .,...ac ai„ri., s.a�.r r �sz•3 tit' /ao P IC8 /Opo G��i,� GR�• � �q V f V OF W ILLIAM v iItA Im C. 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