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Home My WebLink About0117 PRINCE HINCKLEY ROAD - Health 117 Prince Hinckley Road Centerville .P A = 172 194 r PERMIT NO. LOCATION � SEWAGE o 9� VI L LADE ' I INlSTA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER DATE PERMIT ISSUED OAT E CO MPII A NCE I S S U E 0 - (3 � 7Z. ` r r 65` 1 �, No......... �...�... Fick Z:2........ THE COMMONWEALTH OF.MASSACHUSETTS BOARD qF, HEALTH 6 OF....... .. .................. ..... .... ..... --------.. --------------- Appliratiun -fur Disposal Workii Totuuurtiun Prruid Application is hereby`made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System ..y . .. .. .............. .... .....-_. ..................... ------- .......................•._-_-.•__ Loc ion.Address r Lot . . ' .....-- .......................................... .............. ................ ...... ........................................... Owner Address ......_ ... . .... .. ........ ................... ......-------.._..-......-- ----------_......_........_ .. ...._R.... .... ........_._..._.......__.__.... Installer Address Q Type o uilding Size Lot.- .Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ® aOther—Type of Building ..-_-----------------_---- No. of persons---------------..----------- Showers ( ) — Cafeteria ( ) Q' Ot r fixtures ................................ _--------------------- g 6.._. ..gallons per pet-son per day. Total daily flow................................. g W Desi n Flow.......... .... ...........gallons. Ri Septic Tank—Liquid capacit_ .__6 .__.gallons Length---------------- Width................ Diameter...........----- Depth.._......_...... W Disposal Trench—No- ---------------_-- Width..............._.... Total Length-------------------- Total leaching area--------------------sq. ft. x Seepage Pit No..................... Diameter.................... Depth below in t............... ... Total leaching area-------.----------sq. it. z Other Distribution box ( ) Dosing tank ( ) t9 /- /� �f" ' 77 '-' Percolation Test Results Performed by. �y, -_..__-___--.. � ... -...... Date----7/_- :�.� .7_--....... aTest Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water_....................... ri Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ---•-----T --- -------------------- Description f Soil ---_ -----�'--- i1.:�. � �� `"� � _ 2 x � o ,. U ---------- --------- ------- �. UNature 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 XI of the State Sanitary Code—The undersig4ed further agrees not t lace the system in operation until a Certificate of Compliance has been((issued byoar of health. Sig ne 4� 4 .................. `3 Date Application Approved /B _.------- _. ' 'Date Application Disapproved for a Kfollowing reasons:...... .............. .......................................................--_-. .............. ................................----------------------------........................................................................._------_--------- --------__---------_.................... Date PermitNo.....................-................................... Issued_ ��- � ..................... Date ............. THE COMMONWEALTH OF MASSACHUSETTS .-' BOARD OF HEALTH Appliration -for 'Di-uagal Works Tomitrurtion Vrrmit Application is hereby`made for a Permit to Construct ( ) or Repair ( ) an 'Individual Sewage Disposal System a / ram. ------ _---_----------- ` - - --......= ,,- Location-Address f or Lot N .; /{ }, .......... ---=•--.r7.... ae^..................................................... ......-�... ../C...�. ....Ji_=......Address Installer Address Q Type of-Building Size Lot_._./_: -�.. �'' Sq. feet U 74-•--- Dwelling—No. of Bedrooms---------------- ........... -----Expansion Attic ( ) Garbage Grinder aOther—Type of Building _________________________... No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures --•---------------------`-------------------------------------------------------------------------------------------------------------•-••-•------- W Design Flow........ ----------------gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capac0_trr`�-r__.gallons Length________________ Width------.--------- Diameter-----.---------- Depth..._______..--- x Disposal Trench—No_____________________ Width-------------------- Total Length--------------_--- Total leaching area--------------------sq. ft. Seepage Pit No.-_____--.-________ Diameter____________________ Depth below ml t____..._..._._ ._ Total leaching area-------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 * lI' % A" 77 Percolation Test Results Performed by----------- --------- -----------------------_------------............ Date------------------------------------._.. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rl. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ' . 0 Description Soil- --- -C-----'Y c�. U ----- ---- -----------------------------------------•---------------------------------•----------------------------------•----------------------- W U Nature of Repairs or Alterations—Answer when applicable..._..__:_____________________________________________________________________________________ . --------------------------------------...-----------------=--_-__--.---------------------•--------------------=------------ = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to-place the system in operation until a Certificate of Compliance has been issued by t boar of health. ' ----G i - .� ,f -------- ate Application Approved By. = ` ;" - ------------ f +.�7:"" 7 "" Date Application Disapproved for tJTe following reasons:-----------•----------------------.............................................................................. i , •.........................•----•••••----•...._.....--------•-•••--•-----•--••----•••-••--•••-•-•--•-•-•------•----•--••---------------......-------- ----•--------------•`-------------------------•-- Date PermitNo..................................-••-•--•••••--....... Issued-------------------------------------------------------- Date F THE COMMONWEALTH OF MASSACHUSETTS BOARD OF AEALTH ............t..... j ...0 ................ .. . :. 2' ...................................... Trt ifiratr of Tompliana THIS S 0 I hat•the Individual Sewage Disposal System constructed ( 1or Repaired ( ) by.......... e.....•-_. _ ..... ., ' 1-N ''t +, Installer ----------- at. + F. ......'�J' 7 has been installed in accordance with the provisions of : r� j of The S ate Sanitary Coc was described « the application for Disposal Works Construction Permit No. .... ..............,� _-______- dated---------- _, _�__. ............... THE`ISSUANCE OF THIS (CERTIFICATE SHALL NOT BE CONSTRUED AS A .GUARARITEE THAT THE SYSTEM ILI, FUNCTION, SATISFACTORY. �feDATE li"' �--..-e {. ------•------•-•---- Inspector--- -- -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,;HEALTH ...........1.............................OF........ ... FEE •" 3...'" . Di nowt 00x n , ion Vamit Permission 's ereby granted-.... ...r<: ' --------------------- -„-------------- ...-_•-------•---- to Construct ) o . Repair ) an di dual Sewage pokal Syst atNo:... - �` - - ------ ------- ........................... . Street as shown on the application for Disposal:`forks:Construction Pe p..__ ------------ Dhed------- -S ...................... _______-. -___S__ _ _____ __ ____ ________ - DATE........................................................��. o FORM 1255 HOBBS & wARREN. INC.. PUBLISHERS ►�iC?r. GQ,r�a,��r.GR1.��2. ,d11.`•( Clow 11b'x 3 = �3b G.P,p ISD % _ 4 u 7a(SPC?SAt. 'PI'f'` 1JS6 oc�o GAL s ! L € t t i J j � za�l,(/A.t..L �E..A. ," �50 's•�.• } { �s a � M1 ! ; t .. } ' '�Q.'OCJ�} fi.. :� '"S .1,�_ ;. .$ i tc Ste' Vic' .2.5 3"'7S :.PU ? T4 cn g►�' �,� i �lF.�o �ar r.• � Sb C�.PD t � ` t. 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(w i Til•� w + 4 J s .r 1 t �i/ ' $ t'�'- f k I C X4 t was► n L z , fi } t ;�� 1A k I ; a • t � a 6 J}L 3�+ 1 p lye[ l co(a •�" qq x � r ' tr fj � j [•.. t r + f ' '—; i ' �<,t + 't { € � 1 � � Y,.�� ' t , f 'M1, fi ,t � t .� ,,t,.,� p+, QTtFtGC] PILQT, t' /a Eti —'' ¢ �..� �NP ;� � � t ac�'T t U t►J f G�!ra T�„'��t��,�.>� � c I ' { L( Fr 1 v q ti . Y C art1= 'T'�-(A-F. 'TMC� DursP^T- IPIPA 5PQWWR� R.2(t,.i E i,'tt�►.1 .iG[alilPl_�!S V�/1'TF TWAI �' ¢ E2 :AWD �'r �t► `_ �cQu-1QGmE-W of ' �'Nf P�' `x . pp �A. Tom, � � � ; � t-{�z �.,� '•• �°, j L r 1 AEGIS CC-iZ�D '�,�4.t.t�j SU2v4gC))'' T1-Al CJ C,Af-I; t<S 6_1OT t3A5CO 405"fEeull.L 1{ Ir,{'t?c1,+✓tE=t.1'i ,cK��/k=`� "(►aC C:FL ��i 514Ce:JID. ll.�E� C USCG ica t.f::i. �►.(t: Lo'.C' .l�tti �.�_ -t �`.l. A f /�1/�L:,i�.f hkaT• F'� . 1 x TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MBA 02660 -\ COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE. OFFICE OF ENVIRONMENTAL,AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ,J TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED (-'ER"I'IFICATION PropertN Address: 117 Prince Hinkjey Road APR 1 8 2002 Centerville,MA TO N OF BARNS I ABLE ON ner's Name: Estate of Elsie Candito HEALTH DEPT. Owner's Addres,: C/o Paul&Joseph Candito P.O. Box 502,Osterville, MA 02655 Date of Inspection: April 9,2002 Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections 1 Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 (508)385-1300 CERTIFICATION STATEMENT 1 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv"icnr V Passes Conditionally.Passes Needs Further Evaluation b} the Local Approving Authunt) Fails Inspector's Signature: S,1, . Date: y/g /0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I leal(h 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 Although system meets the minimum requirements set forth by the Massachusetts Department of. Environmental Protection,certification is not to be construed as a guarantee of future working condition Of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""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 saute or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I t Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date of Inspection: Estate of Elsie Candito April 9,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: y/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Boar of Health,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statemen . If"not determined"please explain. -- The septic tank is metal al and over 20 years old or the septic tank(w ether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is ' minent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved b e Board of Health. •A metal septic tank'will pass inspection if it is structurally soun of 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 o or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o neven distribution box.System will pass inspection if(with approval of Board of Health): bro n pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: The system r uired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection i ith approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date Of[ri<s ectiott: Estate f Elsie o p s e Candito April 9,2002 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. Sy stem v,ill pass unless Board of Health determines in accordance with 310 CMR 15.303 (b)that the system is not functioning in a manner which will protect p/asea nd the vironment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetatarsh 2. System will fail unless the Board of Health(and Public Wa determines that the system is functioning in a manner that protects the public 6 th,safety and environment: _ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a surface %%ater supple or tributary to a surface wate upply. — The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. — The system has a septic r - and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance "This system passe f the well water analysis, performed at a DEP certified laboratory, for coliforrn bacteria and vol ' e organic compounds indicates that the well is flee from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure cri to are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 i. Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 117 Prince Hincley Road Centerville,MA Owner: Estate of Elsie Candito Date of Inspection: April 9,2002 D. 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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool q Liquid depth in cesspool is less than 6"below invert or available volume is less than %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. p" Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t . An o,� y portion of a cesspool orprivy is within a Zone l of a public well. ALJ* Any portion of a cesspool or privy is within 50 feet of a private water supply well. onion of a cesspool N/A Any P spool or privy is less than 100 feet but eater than 50 feet from a 'v!� private water supply,well with no acceptable PP > p able water quality analysis. IThis system asses if the well water analysis,P Y , 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 forma Nn (Yes/No)The sysittu fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a desig ow 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 ove) yes no the system is within 400 feet of a surface drinking er supply _ the system is within 200 feet of a tributary to surface drinking water supply the system is located in a nitrogen sen . [ve area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply w If you have answered"yes"to any qu ion in Section E the system is considered a significant threat,or answered "yes"in Section D above the Iarg stem has failed.The owner or operator of any large system considered a significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner s uld contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date of Inspection: Estate of Elsie Candito April 9,2002 Check if the following have been done. You must indicate'yes"or"no"as to each of the followine: Yes No information was provided by the owner. occupant. or Board of 1 iealth 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 '? ✓ i 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? _,C __ 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 —Z _ Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] 5 Page 6 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 117 Prince Hincley Road Owner: Centerville,MA r Date of inspection: Estate of Elsie Candito April 9,2002 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:_ I Does residence have a garbage grinder(yes or no): YES Is laundn on a separate sewage system (yes or no): _vu [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no):A Water meter readings,if available(last 2 years usage(gpd)): o = 3o 3c,oo�3 ,t-h, . Sump pump(yes or no): Last date of occupancy: COMMERCIAL/lNDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.2X3do).. Basis of design flow(seats/persons/sg Grease trap present(yes or no): Industrial waste holding tank present(Non-sanitary waste discharged to the T 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 insp ction(yes or no): If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: 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) _Tight tank _Attach a copy of the DEP approval _Other(describe):. Approximate age of all components. date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):Ara 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date of Inspection: Estate of Elsie Candito April 9,2002 BUILDING SEWER(locate on site plan) Depth belu%k grade: /8''> Materials of construction: _cast iron /40 PVC other(explain): Dktancr fron, private water supply well or suction line: /v(w Comments(on condition of joints,venting,evidence of leakage,etc.).- SEPTIC TANK: ,/(locate on site plan) Depth below grade:I' - Material of construction:_Zconcrete_metal_fiberglass__polyethylene other(explain) z If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: 2 '9 Scum thickness: ---rk 1`7 t Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: I low were dimensions determined: Joeul .. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): tin- wo .' t,-:..L.1 c4✓aa.✓. ��o e../_ -Q-e—�Vie, 7'�t��e.yy =�/r _ [� u. - `^ .I r. dl �G.�t1 l.w)�.-� N a_ 4- GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_po thylene_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 to r baffle: Date of last pumping: Comments(on pumping recommendations,in and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leak e,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date of Inspection: Estate of Elsie Candito April 9,2002 TIGHT or HOLDING TANK: (tank must be pumped at time of ins ction)(locate on site plan) Depth below-grade: __ Material of construction: concrete metal fiberglass olyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working orde yes or no): Date of last pumping: Comments(condition of alarm and floa witches, etc.): DISTRIBUTION BOX: L(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.): 11 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,condit' of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 117 Prince Hincley Road Owner: Centerville,MA Date of Inspection: Estate of Elsie Candito April 9,2002 SOIL ABSORPTION SYSTEM(SAS):Z(locate on site plan,excavation not required) If SAS not located explain wh� Type ✓ leaching pits. number: 1 - 6 'k` ' Lt 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.): C y L, r 4 t / S Tti .1 l i f ( 4 (��K✓ t L `. J Lr•.�-- u!� �j Kl t r\S ti ,,Sri`-�•�I'�' G/<,✓i >r ere.1�-o— L✓4- 1 6} h /»e f 4 5✓aa.i c. .f--.-.• o.� 4J u.r i r..� 4 f' .e. �v.--. CESSPOOLS: (cesspool must be pumped as Zeion)ll on site plan) drt `�y ��".K'1-f 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 draulic 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 Zilure, vel of ponding,condition of vegetation,etc.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 117 Prince Hincley Road Centerville,MA Owner: Estate of Elsie Candito Date of Inspection: April 9,2002 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. Ww.r.r�.�,�? P PP Y g Zf Ea,6„ y�• 35�6,. �0 Page 1 I of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 117 Prince Hincley Road Owner: Centerville, MA Date of Inspection: Estate of Elsie Candito April 9,2002 SITE EXAM Slope ,/ Surface water Check cellar ✓ Shallow wells Estimated depth to ground.water.16 a' feet Adjusted high ground water elevation — feet Please indicate(check)all methods used to determine the high ground Hater 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: j94.,f- _. . Checked with local excavators,installers-(attach documentation) V Accessed USGS database-explain: g5 ,, •Z 52. s 3,_A. You must describe how you established the high ground water elevation: �h UG u - ov o� v U U �• a I�j•i�-o•+.• .F f�ti L� �S �y. 7 5.3 Il bV TROY WILLIAMS V 90 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive ._._ South Dennis, MA 02660 �,1 �O ' ,6 COMMONWEALTH OF MASSACI-IUSETTS � -_ - - EXECUTIVE OFFICE OF ENVIRONMENTAL AID DEPARTMENT OF ENVIRONMENTAL PROTE No�f' �`9,9� ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COKE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 7 Pp-,',,c e. k 'o ey R`1• Name of Owner r Corn c K C2h�e_, V r He- Address of Owner:_ 11'7 Pr Date of Inspection: it 6 6 /Cfy Name of k►spector:(Please Pnrrt) Troy 1Nilliamc / 0 2 G 3� I am a DEP approved system inspector pursuant to Section 15.340 of T-rde 5(310 CMR 15.000) Company Name: Troy wlliam's Septic Inspections Maaing Address: 19 Hummel'Drive. So. Dennis, MA 02660 Telephone Number: (508) 385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails kupe to.r s Signature: _ J eta L, (Njt.E JLtCvrv✓1- Date: i 1 /f G ��J� 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 ttte system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. revised 9/2 /98 , _... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owncw: H 7 Prince Hinkley Road, Centerville,MA Date of kupecbon: Harry O. and Shirley J. Cornick INSPECTION SUMMARYOVe Check 6A 19B9 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. SYSTEM CONDMONALLY 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 yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,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) system will inspection if(with or due to a broken, settled or uneven distribution box. The approval of the Board of f 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 2or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PraertY Address: 117 Prince Hinkley Road, Centerville,MA Owner: Harry O. and Shirley J. Cornick Date of lnspectwn: November 16, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 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 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 3of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 117 Prince Hinkley Road, Centerville,MA Property Address: Harry O. and Shirley J. Cornick Owner: November 16, 1999 Dace of Inspection: D. SYSTEM FAILS: /1/19 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 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 SYSTEM FAILS:N/9 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PlIP"Address: 117 Prince Hinkley Road, Centerville,MA O wnef: Date of Ins Harry 0. and Shirley J. Cornick November 16, 1999 Check if the following have been done: You must indicate either 'Yes" or "No" as to each of the following: Yes No ..V _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been Pumped-for-art least two weeks and,the system has been•receivingYtormaf flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. �C _ 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. y _ 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: �C _ 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) / 115.302(3)(b)] y - _ The facility owner(and occupants,if different from owner) were.provided with information on the. SubSurface Disposal Systems. luoPertttaintenance�f revised 9/2/98 Page sor11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address. Owner: 117 Prince Hinkley Road,Centerville,MA Date of Inspectkm: Harry O. and Shirley J. Cornick November 16, 1999 RESIDENTIAL: FLOW CONDITIONS Design flow: /10 g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual):-3 Total DESIGN flow 330 — Number of current residents: Garbage grinder(yes or no): /VO Laundry(separate system) (yes or no):ND ; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): N0. Water meter readings,if available(last two year's usage(gpd): ,9 ' )r a do c ,, Sump Pump(yes or no):_jo S y 7 `s�'j ovu / ct Last date of occupancy:. 0' C-d COMMERCIAL/INDUSTRIAL: AIIR Type of establishment: Design flow:_ and (Based on 15.203) Basis of design flow Grease trap present:(yes or nol_ 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: A/� �JH+D N N i h ✓a. )4 ]/i lJwr.�J It �c Q ►N >t ��o.k System pumpedras part of inspection:(yes or no)LV0 If yes,volume pumped: gallons Reason for pumping: TYPE�eF SYSTEM _ /y 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 Of known)and source of information: Sewage odors detected when arriving at the site: (yes or no) /VO revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 117 Prince Hinkley Road,Centerville,MA Date of Inspection; Harry O. and Shirley J. Cotnick BUILDING SEWER: November 16, 1999 (Locate on site plan) Depth below grade: t Material of construction:_cast iron V40 PVC_other(explain) Distance from private water supply well or suction line IV/-9 Diameter r/" Comments:(condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: � Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age— ls.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: ':�'?C y X 6 ' /6 p p 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: Ea Distance from bottom of scum to bottom of outlet tee or baffle: /e How dimensions were determined: A-1111- .Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structur"tegrity, evidence of leakage,etc.) 1 _V C- '-F- �'c Iar- L. o v f-f' U e a { GREASE TRAP: r9 (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: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integ evi , dence of leakage,etc.) rity revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 117 Prince Hinkley Road,Centerville,MA Date of Inspection: Harry O. and Shirley J. Cornick November 16, 1999 TIGHT OR HOLDING TANK:�(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(ezplain) Dimensions: ---_..._.. ..._...._.. Capacity: gallons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order:Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: J L✓•c, Comments: (note-if level and distribution is a al,evidence of solids carryover, evidence of leakage into or out of box;etc.) a c. L � M PUMP CHAMBER.—A/49 (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.) revised 9/2/98 Page sorii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 117 Prince Hinkley Road, Centerville,MA Date of kupection: Harry O. and Shirley J. Cornick SOIL ABSORPTION k ffA4 9 9 (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:Ch- rX L t 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 soil,signs of hydraulic failure,`level of ponding, damp soil,condition of vegetation, etc.) L� CA- P '/ �/!.� S ♦J I..dt , V-'r'�Y O c/a t,.J i s. -( L.l�v'L. Nit G `` /o o°/t. i�c4. .C.r --�- J�• / V 1 <.c ,h i rb. ✓ �4- ,5*-H�cam✓d3 CESSPOOLS:�i/ ;l �— o✓�rabC�»,s 1 h d-. wr-c.. ,� �►^c.S-ch-f cx-�- ;s -(locate on site plan) / As,.� 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:Lv/9 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ertt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 117 Prince Hinkley Road,Centerville,MA Date of Inspection: Harry O. and Shirley J. Cornick November 16, 1999 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) c3a�k � I 5 7'6 „ 55 6 3d yg 3s 6 �000pt �o-rt�C. revised 9/2/98 Page 10orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ownef: 117 Prince Hinkley Road,Centerville,MA Dace of Inspection: Harry O. and Shirley J. Cornick November 16, 1999 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 15fFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abuttin / g property, perty, observation hole, basement sump etc.) V 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 you established the High Groundwater Elevation. (Must be completed) / V� V 5 /�'10.P 1 S '1 o 4J L�✓N. k A LA j o�.t tr l-C.✓t 1 �.y��6✓ �5 / 3 / rc, 7'ql revised 9/2/98 Page 11 or 11 rS Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection Jolui One winter Street' D.E.P.P. Titlee V Septic Boston Ma. 02108 epi tic Inspector kip P.O. BOX 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Z� —11 Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A 11 CERTIFICATION RECEIVEO O Avekle-Y OCT2 0 19 Property Address: 117 Prince iiXley Rd.Centerville Address of Owner: 9/ ,A Date of Inspection: 10/16/97 (If different) TOWN OFB4RNSTgg Name of Inspector: John Graci Norma Smith EALTHDEpT LE I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: rQ L � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This inspection Is based on criteria defined In Title V ConditionaIV Pas es code 310CMR16.303.My findings are of how the system Is performing at the time of the Inspection.My inspection does _ Needs Fu 0 er luation By the Local Approving Authority not imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature: N Dater iw6197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 04127S7) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10/16197 _ SewaQe backup or,breakout or hiah,static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool Or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10f16197 D]SYSTEM FAILS(continued) 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). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no 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 SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10116197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X— — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)]15.302(3)(b)] I (revlaed 0412M) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:101"18197 FLOW CONDITIONS RESIDENTIAL: Design flow: 3m g•p•d./bedroom for S.A.S. Number of bedrooms: J Number of current residents: t Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): nta Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: nta Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nta Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: Maintenance TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components, date Installed(If known)and source information: 1979 Sewage odors detected when arriving at the site:(yes or no) No (revised 04r17)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10116197 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age_o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'e-•He-7"w4'10^ Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle:23" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 1s" How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle:roa Date of last pumping;,(- Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rya BUILDING SEWER: (Locate on sne plan) Depth below grade: TV Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line?o— Diameter: 4" Qmments: (conditions of joints,venting,evidence of leakage, etc.) I (revised 04127l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10r16197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: n1a Capacity: rda gallons Design flow: rya gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) The D•box Is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_y.. Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rea (revised 06127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 117 Prince Hinkley Rd.Centerville Owner: Norma Smith Date of Inspection:10116197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: We, Type: leaching pits,number: 1.=gallon leach pit leaching chambers,number:nla leaching galleries, number: rda leaching trenches, number,length: nia leaching fields, number, dimensions:rda overflow cesspool,number:nla Alternate system: nia Name of Technology:_rva Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit Is auucturally sound and functioning properly.It had 2'or water In It CESSPOOLS:_ (locate on site plan) Number and configuration: n!a Depth-top of liquid to inlet invert: rda Depth of solids layer: nla Depth of scum layer: nia Dimensions of cesspool: nia Materials of construction: We, Indication of groundwater: nia inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: nla Dimensions: nia Depth of solids: rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla (revleed 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 117 Prince Hinkley Rd.Centerville Norma Smith 10116197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) V A [j f. �Q A B 3°� EA 3s c (revised0027197) Page ! os? a0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 117 Prince Hinkley Rd.Centerville Norma Smith 10116197 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts r (revised04R7197) irage 10 of 10