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0147 PRINCE HINCKLEY ROAD - Health
147 Prince Hinckley Road, Centerville L0 C AT1 �5� SEWAGE PERMITM1 NO. �'� 78-114 VILLAGE INSTA LLER'S NAME S ADDRESS Alfred Fuller West Barnstable Rd. Marstons Mills, MA. BUILDER OR OWNER Alan E. Small, Inc. Box 536 Centerville, MA. DATE PERMIT ISSUED Mav 3, 1978 DATE COMPLIANCE. ISSUED �� 117�-- 9 r y y �w,L s. t it E7 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD 9,F HEAL , H OF....... ... .. ...... ........ .................... Xpli iration -fur 43iivuuttl Works Tomitrurtiutt Prruift Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . %_...��_---- , _ -----_..... . ....... anon• -ddress of No. ................. .�........... .... ............................... ...... ----•-----'-----------.- .......--•-t..........._.................__................ er Address a .............. .... ... -•........ --l----•"----_..._._...-----_...----------•- ------ / .-=--•-•-----.._.....-•-`--•---........_................. Installer Address Q Type of B ' din Size Lot../I$_ �___Sq. feet Dwelling ding of Bedrooms--------------------------------------------Expansion Attic (IV6 G.- age Grinder ( � aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------ W Design Flow...................r. _._._ Mons per person per day. Total daily flow------- __-___-_-.---gallons. WSeptic Tank—Liquid capacit __ II Ions Length---------------- Width................ Diameter---------....... Depth---------------- x Disposal Trench—No. .................... Widtli....__._. . Total Length-----------------._. Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.4�, Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ) 0/ . f,- 7- 7 7 '~ Percolation Test Results Performed by -- ._ . /1Pai0__._.... Date._ �� _'"__7 _____-- a ,4 Test Pit No. 1................minutes per inch Depth of Pest Pit-------------------- Depth to ground water____________.._._....... 0-4 Test Pit No. 2................minutes per inch Depth of Test Pit_-_________-_____ - Depth to ground water__.__-______________.._. ----- -- - --- O Descr1 do f So' - -'� .1- _9�.. 2 - �z n- U �f4--- --------------------------------------------------------------------------------------------------------------------- UW .......... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 XI of the State Sanitary Code—The undersigl d further agrees not to place the system in operation until a Certificate of Compliance has been 'ss, ed by the boar of health. gne - ------------------------•--•-•--- �"� / Date l Application Approved By............ .. . ....... ....... -- ....... ...l...... ` •�•= - 7i��-- ... Date Application Disapproved for the following reasons:..............................................- .................................................--------------- ...._.....-•---------•-•-•---••••---...-•-•-••---•------•---•-•--------•-•--•-•-•---•-•••-----•-•----•---•----------------------•---------------•-•-- ---------•---- -----------------.----------------- Permit No.......................................................... Issued------`-k�_ Date Date No.--------- ............... THE COMMONWEALTH OF MASSACHUSETTS J� BOARD OF HEALTH ... . ...... .......OF....... .. ......... ... .......................................... Appliration -for Uh5pviiat Works Tvw4rurfion Vrrnift Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ------- ....... ......................................................................... ......................... -,Address of No.. _ee�A, Address ...................................................... ...............W...-................`/ram........................ ------------------------- Installer Address !11 Type of Bdildl Size Lot_2��5.... --- Sq. feet U Dwelling Wo. of Bedrooms--------------------------------------------Expansion Attic Garb/age Grinder a4 Other—Type of Building ---------------------------- No. of persons_-_____.-.______---.-.__-- Showers Cafeteria Otherfixtures ----- ------------------------------------------------------------------------------------------------------------------------------------------ Design Flow...................57.!r-----------gallons per person per day. Total daily flow........*2.. .._..........gallons. Septic Tank—Liquid capacit/V _A715-fallons Length________________ Width___--------- Diameter_...........____ Depth.-.--._:_....... Disposal Trench—No---------- ......... Width___-:.-__{ Total Length-_____--_-_---__-_-- Total leaching area-------_-----------sq. f t. Seepage Pit No..................... Diameter_j��-.,:��,, -*--Depth below-inlet____...._....__.-___ Tot aUeachingarea------------------sq. ft. Z Other Distribution box Dosing tank 70,� 7-7 Percolation Test Results Per-formed by ... ..--- --(i_1. .. -4 4*9-JeA...... Date.. ----- ---------- ---- -- i_.. Test Pit No. I................minutes per inch Depth or-Test Pit...--_--____-__-_-- Depth to -round water...-_-.-.----.---.-..... Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------- ------------ - - ------------- -------------------------------- ------------------------------- --- ----------------------- ---------------------------------------------- ----------------- 0 Descript' f SO* - I - 2 , 9 0 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 XI of,the State Sanitary Code—The undersigVd further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the boar of health. n ... . .. .......... ...... ------------------- 2& d, .. .. ----------------------- Application Approved By....... 00001000 Date .0.. .. 7, 7 F,--- Application Disapproved for the following reasons:--- ------------------------------------------ Date ------------------------------------------------------------------ ........................................................................................................................................................................................................ Date Permit No. =:� ............................ Issued...................... -------- ........ .............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF . ............. ..... .OF.....-......:.. . . .... ....................... Tntifiratr of Tlimpliana 4�1 Q01r THIA, Ir/' 0 T That the Individual Sewage Disposal System constructed �o, Repaired by....orn. Ae....... ............................. ...... . ... . .... .... ........................................... Install --- ---------- ........................................... at... ... ..... ----- j..7. -------j.'has been installed in accordance with the provision of 'k is I of The State Sanitary Code as d cribed-in the 7 a. 4_.._ _7 application for Disposal Works Construction Permit N .. . ......./`/`-`-.,.Y---------- dated...... ............. THE. ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC a'��O N,-,;SATIS FACTORY. DATE...................r 10P ......................................................... Inspector-----------------------------�t;............................................. T s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7�9 ............�' OF.... .. 1,L . ......... FE&....................... ion Vrrmit Permission reby granted-_ Adl IT----- - --- -------------....... ............................................................ o Con�truci t 'epair..4an Individ........Sewage Disposal System ................................................... ------------------------------------------------........... Street as shown on the application for Disposal4orks Construction Permd po... .............. K . B td of Health 1% .0' DATE.................................................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ���trJGU& IPO.M1l_`( � T i✓T7jZL�0N� �- ' _.._ `y` QO 6,A28AGG-- C�rzl�1D�2 Pi c� �a L.�-{ Vr Low = t G v- 3 = S3O G.P.V. I �E�ic TAti11C = 330.e ISO % * 4.-95 6-P.D. - u Ste- t oao 6�s.L. ` 8 _l ISPaSA� PiT - U5E loco G&.L- . IS'.000 tT.ew�LL AOJEA = tso :2 Bc*T- OAA 42MA_ D ST-. _1 c5D fog. ot t .o = So (a .P D. _` v t TOTAL vac- l�►.I % d25 G.RD. PIT L`J - F C F�t✓ • 4 V PSf2CDL&TlC)Q 2&TE l" 2._A(IW2 0 LESS. I '�- EX p, : 'r T 9//7/77 TOP Pwo =ioo.o 0- _310. q7 j .nrr.•�... LoAp1 ppe �� I oao i►N. �;� 5u �atE. 4'pp" ViSr. 1W 64L. W-7 Z f fox 74,4 S�r-ic to . wv. TA 14 W- I I o00 . 1 t�Nv �uv. GnAV GL Lat 9G.o 9G. Z a PT WiT�1 •; WASHED s�oNE 89.8 WED S JD CF=QTti✓11=ID pL-bT- Ptzo�i L� - LoCATIo" CENTl KVt LL C u o Sc Lt=- SCAL o /V o W.9 TEP Cl lz-rlVz—; Ts-(A-r TNG FOVNDATtGMWc-- tQ PLAt�1 T2i_h�.RcG.lC t= t-1r.i�t ►,l Gc �PL�(S W rTtA TWGl : L 07 E3 -7 A.u� :ETC-.At1� �'G4�.st�EAs1�:uTS ct` -r�►+t= 42E G t S'tT=iZi=L� 'l-A 1-1 G 5U 2�i isYv►=.:� �'t {l5 t7t_Atit tom, 6�UT ti;A�>EC7 Ut.i A�.l USTEV-VkL-G o IVCAS�i• tW Yi•?J:n L:W i ��CJ::�/l am x "T►a[j UFI=S C'�� e7!tGt.1LD APt� LI GAF-J T c.,l>L-f-.N icy Commonwealth of Massachusetts rl Title 5 Official Inspection Form ICI.-= Y jo Subsurface Sewage Disposal System Form - Not for Voluntary Assessrne-ts Proper Address L Gf►^ G r-e,7 �.✓G f Owner Ow er's Na e n� required forinformation k (�� 4e✓'C/,'Ili -- / m Od 6.3a a — y— 0 5� -- every page. City/Town State Zip Code Date of'r.scecicn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms the f t 53 b computer, r, use 1. Inspect I only the tab key to move your or. cursor-do not Name of Iryspector use the return key. / ll'O �/ - Company Name I ie,--0 Company Address cf i ren!m City/Town State Z!p Code tso�U 2 0- ly/80 Teleohone Number License Number B. Certification 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 ins ection was performed based on my training and experience in the proper function and ma;ntenance of or: s to sewage disposal systems. I am a DEP approved system inspector pursuant to ectione1 .34g,of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes i❑ fzj CD Needs Further Evaivation by the Local Approving Authority Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Aporovi;is rAI t` ay �carw of Health or DEP) within 30 days of completing this inspection,. If the system is a. snared has a design flow of 10,000 gpd or greater, the inspector and the system owner s ,al su'o--,c t"e report to the appropriate regional office of the DEP. The oneinal should be sent to the and copies sent to the buyer, if applicable, and the approving authority. ****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. �_ t5insc•03le8 Tula 5 Offici2l 6�s?action Fcmi:c.;^�_^;__ _ __ _= r - _ Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Vol!ntary Assessments Property Address � Owner Ow is Nam informationis required for e o-fie every -- every page. City/Town State Zip Code rate of!nspect:or B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) ;1,e asses: I have not found any information which indicates that any of the failure criteria descried in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: //� ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair. as aopro%ed dti' the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. 1`"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether meta' or nit) a 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, no= ea,.. c, ten.: if 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 di_tr: i_ "_.cx I;e to broken or obstructed pipe(s)or due to a broken, settled or uneven Gist ib c•r ^c: c.. j" pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced 71 obstruction is removed t5inso•03%08 Tide 5 Official In_oecfien=Crm' Commonwealth of Massachusetts Title 5 official Inspection Forma �-s) Subsurface Sewage Disposal System Form - Not for Voluntary Assessme-:`s \��j rl✓1Ge ��n��! �d Property Address Owner Owner's Name /l Q information is / l required Tor every page. City/-own State Zip Code Date of ins eC ior: B. Certification (cont.) B) System Conditionally Passes (cone.): i ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed oipe(s). " e system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: /� ❑ Conditions exist which require further evaluation by the Board of Heal;", in order to deeri� r.e !f 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 ❑ vegetated or privy is within 50 feet of a bordering veetated v:etla c a- a sa' ars 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 syste„ (SAS; �i' 100 feet of a surface water supply or tributary to a surface ;!rater supni; . ❑ The system has a septic tank and SAS and the SAS is within a Zc^a _- _.e supply. ❑ The system has a septic tank and SAS and the SAS is vrthin supply well. t5ins�'03/^8 idle 5 Otl—n!11-sDeCu3711=__...__.,_ ._a S=:•r__- r_.s_ ._ •_---__ r Commonwealth of Massachusetts Title 5 Official Inspection Form 1=I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessmer: s Property Address __ Owner Owner's Name inform,a;ion is a 0-k i/i /lam 6V 6 36� a - /y— 17 reGured for every page.e. City/Town State Zip Code Date .c !rspe %or B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): N/ ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fee" 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, 'or col OFF bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitro`er, ;s equal to 31- 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: D) System Failure Criteria Applicable to All Systems: You must indicate `'Yes" or"No" to each of the following for all inspections: Yes No El Z/ Backup of sewage into facility or system component due o o:eric ed / clogged SAS or cesspool ❑ �( Discharge or ponding of effluent to the surface of t^.e gro cr uuu due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet in: = to an ^•'e`I. -o d or clogged SAS or cesspool ❑ �� Liquid depth in cesspool is less than o' below Jiinv . . or 4 a . - than '/z day flow ❑ Z/,*�— Required pumping more than 4 times in the last yea,- N'OT-,,,e o l cc obstructed pipe(s). Number of times pumped; ❑ [[E"'� Any portion of the SAS, cesspool or privy is belov,/ high+ cro3�,,- ! Any portion of cesspool or privy is within 100 feet o`u sup-- e 's- ❑ tributary to a surface -eater supply. tSins„•e_ios Tice 5v�aai 1;- =_c;io-.=,,. .:9____r__e__._-=_._:_:. -e- -_ - _ _ Commonwealth of Massachusetts n Title 5 Official Inspection Form 18i Subsurface Sewage Disposal System Form Not for Voluntary,-,SsesJ���e��ts / Property Address / Owner Owner's Name information is �1 _ 4r !V/ e X4 ©�-T� a — Gf — O 5 required for — -- every page. CityfTown State Zip Code Date of inseect on Be- Certification (cont.) D) System Failure Criteria Applicable to All Systems (coat.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public vrell. ❑ [✓� Any portion of a cesspool or privy is within 50 feet of 2 private v:2ter su o'y :vel!. ❑ ❑ 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.] ❑ The system is a cesspool serving a facility with a design flo,.v of 2000gpd- ❑ ;,'-- The system fails. I have determined that one or more or the above fair!;e criteria exist as described in 310 CMR 15.303, therefore the sys-ern iai;s. 1 ne 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addit on t e questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface driv ing �a'ater p-p`y ❑ ❑ the system is within 200 feet of a tributary to a surface dri-:`,k17:c the system is located in a nitrogen sensitive area `n-erM - -- n'e^` r: ❑ Area — IWPA) or a mapped Zone ii of a public v,,ater suoci J -;aJ4- Ii'you have answered "yes"to any question in Section E the syste is Corsi - or answered "yes" in Section D above the large system has failed. The ov;,-4 12 - system considered a significant threat under Section E or failed under Section G s ai ^'a system in accordance with 310 CMR 15.304. The system owner should cc, tac regional office of the Department. .5msp•03'08 _ Commonwealth of Massachusetts Title 5 Official Inspection Form �;i Subsurface Sewage Disposal System Form Not for Voluntary Assessmerts Property Address Owner m Owner's Na inf lam" nforzticn is c _14 required for vat 77 every page City/Town State Zip Code D2te c f inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each! of the Yes No ❑ [� Pumping information was provided by the owner, occupant, or Board of ❑ Q/ Were any of the system components pumped out in the pre,:'ious t,Jo Ateelks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as par-. of ❑ this inspection? Were as built plans of the system obtained and examined? (If they were no 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 cn site? ❑ Were the septic tank manholes uncovered: opened; and the inte-ior of the inspected for the condition of the baffles or tees: nnaterial of construction, dimensions, depth of liquid, depth of sludge and dept of scum? ❑ Was the facility owner (and occupants if different from owner) provided information on the proper maintenance of subsurface sewace d`s.ocsell sy-zeMs ' The size and location of the Soil Absorption System (SAS) on the site 7-s been determined based on: Existing information. For example, a plan at the Beare of ea!:'.. u ❑ Determined in the field (if any of the failure criteria re":.ated to =ar C at s e approximation of distance is unacceptable) 11310 CMRR ;Sirse•r_.3rog Subs c=,,--= THI=cOrid21L^g,e.�sorco—. _— - - -'_____'� =--•'___=_:._ Commonwealth of Massachusetts :a== r Tide 5 Official Inspection Form i l Subsurface Sewage Disposal System Form -Not for Voluntary Assessme^: s 4-le- Property Address 1/v� / fOwner Owner's Name p / /l / l / Q nformation is !/1 A, �/7 O�6�o`— � —/ Z/ —L / required for --- — every page. City/own State Zip Code Ca:e D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms !actual;: DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents: Does residence have a garbage grinder? lI Yes I� No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes !ice No Laundry system inspected? I—J Yes NO Seasonal use? P— No Water meter readings, if available (last 2 years usage (gpd)): -- Sump pump? I `,es y � Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gall ns er da ( pd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? _ Yes \° Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? "es Water meter readings, if available: -- -- Last date of occupancy/use: Date Other (describe): t5inso•03,08 Tile 5 O-ds!Inspedion ..__s_c=_=_a._=e__z:- -.__ . z;= _ Commonwealth of Massachusetts a; rz Title 5 Official Inspection Form SET : a cJ Subsurface Sewage Disp�al System Form - No,for Voluntary A s ssm..r.s . Property Address Owner Owner's Name / �/� / information is h- ek---vl lie- /°��! p10 LU p2 _ �Lf �1—'_ required for - — — every pace. City/Town State Zip Code Cate of nsoec`ion D. System Information (cont.) General Information Pumping Records: OY Source of information:Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons How was quantity pumped determined? — ---- -- Reason for pumping: --- Type of Sys m: 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 cure-,t operation —id maintenance contract(to be obtained from system, owner), arc, a copy of later 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 compon ts, d to installed (if own and source of i ,`wr;a.io Were sewage odors detected when arriving at the site? ;Sinse•G3/Cc� Title 5 0`iiciai;rsc ..cr -..-- _:- _---- - -'- •_---_ _ Commonwealth of Massachusetts = r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form /-Not for Voluntary.Assess—ners Ale Property Address Owner Owner's Nam, /inicrmatlon is Cc 117 ��/✓/Ile 3-L required for -- Da`- every Page. City/own State Zip Code c•s!nsp=_g ion IJe System Information (cost.) Building Sewer (locate on site plan): Depth below grade: ;eet Mate ria! construction: cast iron �40 PPVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): /Septic Tank (locate on site plan): Depth below grade: `eet Material o nstruction: fiberglass ❑ polyethylene ❑ ' other (exr';�i :) concrete ❑ metal ❑ 9 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No -------------------------------— ------------------ --------------------------- ------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle — a9 Scum thickness Distance from top of scum to top of outlet tee or baffle — r Distance from bottom of scum to bottom of outlet tee or baffle C4yi C� How were dimensions determined? :5inso•mlos Tile 5 Or ci21 Insoercion=o,-. c-=- -e --- = L Commonwealth of Massachusetts Title 5 Official Inspection Fora 1,Vi—� ri Subsurface Sewage Disposal System Form Not for Voluntary F,ssess ner:. s Property Address � / V '11 Owner Owner's Name / 1 information is N 4erv, lle— 1Y�4 as 6 L p2 — "/ — O reouired for — every page. City/Town State Zip Code Date of ins._o is n /b_. Syste�mlnform�aton (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condaion; struc -;ral ir,`=erity. liquid evels as related to outlet invert, evidence of leakage, etc.): ��N� ��� eS l ✓> 00, Cvh�, /��, / Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑, ot1 her 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: Dafe Comments (on pumping recommendations, inlet and outlet tee or ba-ie cor:diticn, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass II l pclvef,;;e ,e ❑! o -- _ :5insD•C3108 Title 5 Crci21 Commonwealth of Massachusetts n MIN 5 Official Inspection Form 1Rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Ov✓ner's Na '`/�/ / informa' 2�9 or is � ✓ Iyi / A46 z _� _ Orequirecfor -- �(t- 7 every page. CitylTown State Zlp Code D=e of 1n,spectio D. System Information (cost.) Tight or Holding Tank (cont.) T' Dimensions.- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: i 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? 0Yes ❑l No Distribution Box (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 carrvc:e . ant- evide ce of leakage into or out of box, etc.): o.� Level 1 Pump Chamber(locate on site plan): / Pumps in working order: ❑ Yes ❑ :c Alarms in working order: ❑ Yes _ '.Sins •o3/o8 � T;.tl=5 Cffir.21 Inso=_Mier=crr,:S.:�s_ _�_Se._ ___--'' -.e •---- - Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Di posal System Form - Not for Voluntary Assessments _—c=Z' Property Address �--2— Owner Owner's Nam ` information is required City/ State Zip Code Dzte o` every page. Da System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances. etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: YP C'X P w I 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 o, pcncir.' , ca, _, s3il. cor-:d s vegetation, etc.): Dt- ainso•03!03 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address V / — e2e— Owner Owner's Name �y iequirE tion is / 4��1 //e- /�� 0d 6�� '2 -/Lf_ a reeuired.or Ci G / / — every page. City/Town State Zip Code Date of L nsoec`on D. System Information (cont.) 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 L ll Yes if No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of veget ton, etc.): Privy (locate on site plan): Materials of construction: - Dimensions — Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of pcnding, con-ition or- etc.): 5nso•03i,8 TJ>50fiici2l InSOECtioa-_. ... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess:-me;;ts Property Address Owner Owner's Name w l LLJJ information is N P-V e / "i v/ Da& 7' required for every page. City/Town State Zip Code Date of! s on D. System Information (cons.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage dispesG! sys`em includi�, es to at least two permanent reference landmarks or benchmarks. Locate all wells,,;;" i:, 1 150 Locate where public water supply enters the building. � B i 14 d, 35 �3 - 0 f �i- c,2 5 i5insp•03/08 Title 5 Official lr,spacticn Fc-T: Commonwealth of Massachusetts ii:21 Mir Title 5 Official Inspection Form Ia > Subsurface Sewage Disposal System Form Not for Voluntary Asses s-:e-!a Property Address Owner Owner's n information isv� /�� /�� �a 6 ?1 - y D required for --------- evw o2ee. City/Town State Zip Code Qa.-. ,n� - tb r. De System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar v ❑ Shallow wells i 02� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: from system design plans on record Obtained o ❑ Y 9 If checked, date of design plan reviewed: D2te — ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with loc I Bo of Health - explain: — --- ❑ Checked with local excavators; installers - (attach documentation) ❑ Accessed USGS database - explain: You must escri` e how you established the high ground w ter elevatior;: O v`? _0 � �" I t5insp•03/03 Title 5 _- L Commonwealth of Massachusetts Executive Office of Envirolnnental Affairs c Dept. of Environmental Protection One winter Street'Boston Ma. 02108 John Septic D.E.P. Title V Septic h>-Spector P.O. Box 2119 Teaticket MA 02536 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI A Lt.Governor SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECTION FPART 4/'^ 1ji�o CERTIFICATION r7 1,9 I„r Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Address of Owner: gg� Date of Inspection:8/12197 (If different) Name of Inspector:John Graci Estate of Stern I am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15.000) t Company Name,Address and Telephone Number: Y i~ 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 - Conditionally Passes code 310 CMR 15.303.My findings are of howthe system is performinq at the time of the inspection.My inspection does NeedsF he EvaluatlonBytheLocalApprovingAuthority not imply any warranty orquaranteeofthelongevityofthe Falls septic system and any of its components useful life. Inspector's Signature: �fN Date: 8113197 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 04/27/97) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9,Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner; Estate of Stern Date of Inspection:8/12/97 _ Sewaae 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 duc to an overloaded or cloyycd cesspool. SAS is in hydraulic failure. (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner: Estate of Stern Date of Inspection:8/12/97 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 F 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 II 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 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner: Estate of Stern Date of Inspection:8/12197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _x_ — 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 NIA. 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)) (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner: Estate of Stern Date of Inspection:8/12/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g•p•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 0 Garbage grinder(yes or no): No 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): n/a Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: n/a 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: n/a Last date of occupancy: n/a OTHER: (Describe) n/a 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)No If yes,volume pumped: 0 gallons Reason for pumping: n/a 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: 1978 Sewage odors detected when arriving at the site: (yes or no) No (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner: Estate of Stern Date of Inspection:8/12/97 SEPTIC TANK: x (locate on site plan) Depth below grade: 1' Material of construction:x concreale metal FRP Polyethylene_other(explain) If tank is metal, list age 19 . Is age confirmed by CePt'Ificate of Compliance Yes (Yes/No) Dimensions: L8'6-H5'7-W4'10' Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 25" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 0 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 septic system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n/a Material of construction: _concrete metal_FRP_Polyethylene_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping,va 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.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 16' Material of construction: cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line?own Diameter: 4' i;18mments:(conditions of joints,venting, evidence of leakage,etc.) (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Prince Hinckley Rd.Centerville Lot87 Owner: Estate of Stern Date of Inspection:8112/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: rrla Capacity: n/a gallons Design flow: n/a gallons/day Alarm level:_n/a Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n/a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n/a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Prince Hinciday Rd.Centerville Lot87 Owner: Estate or Stern Date of Inspection:8/12/97 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: n/a Type: leaching pits, number: 1,000 octagon gallon leach pit leaching chambers,number:n/a leaching galleries, number: n/a leaching trenches,number, length: n/a leaching fields,number, dimensions:n/a overflow cesspool, number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The overflow is structurally sound and functioning properiy.lt has not had more than l'of water in it. CESSPOOLS: (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: nla Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) Iva Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/e PRIVY:_ (locate on site plan) Materials of construction: We Dimensions: n/a Depth of solids: n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n/a (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 147 Prince Hincldey Rd.Centerville Lot87 Estate or Stern 8112/97 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) hA R6 0 At 1' (revised 0427/97) page 9 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 147 Prince Hincldey Rd.Centerville LoW Estate of Stem 8/12/97 Depth of groundwater Q, 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 (revised D4/27/97) Page 10 of 10