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HomeMy WebLinkAbout0217 PRINCE HINCKLEY ROAD - Health 217 Prince Hinckley Road Centerville .P A 171 113 COMMONWEALTH OF MASSACHUSETTS z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION / J TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM �VED PART A CERTIFICATION APR 1 8'2002 Property Address: C� /T/� �i ✓1G� /-c4/e�j �c/ L'r✓�11 �6,�, - `-2 TOWN OF B DEPT. Owner's Name: e v)c1 l ��, c Owner's Address: 9, Sf Date of Inspection: Name of Inspector: (please print) Company Name: Mailing Address Telephone Number: Sc y) y CERTIFICATION STATEMENT / I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: V passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: / c Date: 3"' a' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: ULA s Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1L l anve not found anv information which indicates that anv 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: A/ 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. Answer yes.no or not determined(Y,N,ND)in the for the following statements. if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurallv unsound,exhibits substantial infiltration or enfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �4' 0 /-/1V7cl,-/r. Owner: 6 6 LA C- S Date of Inspection: Z--�? C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or pricy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis. performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: We Ile Owner: J a,c cz, S Date of Inspection: 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 _✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow _,Z'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. _ Any portion of 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. 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 .vater quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] �(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303..therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no" to each of the following: (The following criteria apply to large systems,in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��✓l�� /7111" Owner J C�7 C: y, -, ,. S Date of Inspection: —7 --,,Z;2 _ c z Check if the following have been done.You must indicate`ves"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health ``—/Were any of the system components pumped out in the previous two weeks . Has the system received normal flows in the previous two week period // Have large volumes of water been introduced to the system recently or as part'of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up l/ Was the site inspected for signs of break out Were all system components,excluding the SAS, located on site Were the septic tank manholes uncovered opened,and the interior of the tank inspected for thecondition Pe pest of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: YOno 'Existing information. For example;a plan at the Board of Health. Determined in the field if an of the failure criteria related to P i— — ( Y art C s at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] a Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '� �' "'ice �f����G✓!E i2�� Owner: J U7c CZ L-1 Date of Inspection: FLOW CONDITIONS RESIDENTIAL 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: U Does residence have a garbage grinder(yes or no):yO Is laundry on a separate sewage system(yes or no):/V0 [if yes separate inspection required] Laundry system inspected(yes or no): ,119 Seasonal use: (yes or no): Xe Water meter readings,if available(last 2 years usage(gpd)): 010 o D — 22 Sump pump(yes or.no):4-61 / Last date of occupancy: 74/ieo T COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: - — O��✓'�rr Was system pumped as part of th6 inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: Tl'1�E 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/Altemative 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 wr})and source of information: Were sewage odors detected when arriving at the site(yes or no):ZV62 Page 7 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �4,- 4-le (v�� Owner: e ;�z ti e S Date of Inspection: -BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_/cast iron V 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:Lf(locate on site plan) Depth below grade: Material of construction: 1/concrete_metal_fiberglass_polvethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ,�t// Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottojp of outle t tee or baffle. How were dimensions determined: 1c-_ ,r«ti Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels /a/JC jSelated to outlet invert,.evidence of leakage.etc.): GREASE TRAP: �00_cate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (21 1 Y%I✓��� /� n �r'�p �� Owner: 7—rA C (X-ur,S Date of Inspection: 3—a 2- TIGHT or HOLDING TANK: must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: >?allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (/(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0e2-,vv7v Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into ofy�}�ut of box,etc.): PUMP CHAMBER: locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: aci Owner: )_o7 fl-a v1 e 3- Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: TyV leaching pits,number: X �� fit✓ 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.): ._ / i CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p� �j'' 0-2Z� Owner: ✓ a/C GZ u e Date of Inspection: 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. G /"'1 �) T-=T (QD1 /0070 1 it tic ��b Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 d'%l <� Aram�-le C� ✓//e� /9 y�'6�oZ Owner: Jac r2 i w Date of Inspection: �— -o SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water / feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: "Siserved site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: G�S Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe.how you established the high ground water elevation: I N a✓a 0/ Tom !%7--- C7— G tY 00 ' o v I � O © 1 / e _ Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection John Grad • One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 TeatickeIv1�02536 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION lyy01- t �(ly�,ysr Property Address: 217 Prince Hinckley r.Centerville Map 171 Lot 113 Address of Owner: Fpl9B�E 4 Date of Inspection: 4/24198 (If different) Name of Inspector: John Graci Kathleen O'Neill:128 Pleasant St.Bass River�uth Yarmouth 026, I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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 _ ConFubmit SSeS code 310CMR16303.My findings are ofhow the system is performing at the time of the Inspection.My Inspection does _ Neevaluation By the Local Approving Authority not Imply anywarrantyor guarantee ofthelongsvllyofthe Fail septic system and any Oita components useful life. Inspector's Signature: Date: 4127198 The System Inspector shallpy 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 CoMpllance(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 exfiltralion, 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 007197) One Winter Street is Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 211 Prince Hinckley Dr.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant St Bass River South Yarmouth 02004 Date of Inspection:4r24199 _ Sewage backup or.breakout.or. hioh.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 15 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 (appro)dmation 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 0427ST) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant tit Bass River South Yarmouth 02084 Date of Inspection:4124199 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 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. (revleed 04127)97) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant tit.Bass River South Yarmouth 02084 Date of Inspection:4124199 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)) pevleed 04f27l97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant tit Bass River South Yarmouth 02064 Date of Inspection:4124199 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•P•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 3 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): rda Sump Pump(yes or no): No Last date of occupancy: nls COMMERCIAL/INDUSTRIAL: Type of establishment: ma 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) Na Water meter readings,if available: nfa Last date of occupancy: nla OTHER:(Describe) rds Last date of occupancy-.- GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nla 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: 1996 Sewage odors detected when arriving at the site:(yes or no) No (revised 041210T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant SL Bass River South Yarmouth 02664 Date of Inspection:4124199 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 run . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L8'6"H6'7"w4'10" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:24" Scum thickness:4" 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: 14" 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 ere structurally sound and functioning property.Recommend pumping now,then every two years and recommend moving sprinkler Ilne. GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda 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:rda Date of last pumpingN 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 2V Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction lin0o­ Diameter: 4" rwimments: (conditions of joints,venting,evidence of leakage,etc.) (revived 04R7187) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Prince Hlnckley0r.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill:128 Pleasant St.Bass River South Yarmouth 02884 Date of Inspectlon:4124198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: - Capacity: rda gallons Design flow: rda gallons/day Alarm level:_wa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Na Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ es Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revlaed Od1t7197) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 217 Prince Hinckley Or.Centerville Map 171 Lot 113 Owner: Kathleen O'Neill;128 Pleasant tit Bass River South Yarmouth 02064 Date of Inspection:4l24I88 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: Na Type: leaching pits,number: one 1000 gellon leach plt leaching chambers,number:Na leaching galleries,number: nla leaching trenches,number,length: rda leaching fields,number,dimensions:n1a overflow cesspool,number:Na Alternate system: Na Name of Technology:_rda Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Leaeh ptt and all components are structurally sound and funcdoning property.Leach pit Is half full. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet Invert: n►a Depth of solids layer: nta Depth of scum layer: rda Dimensions of cesspool: nla Materials of construction: Na Indication of groundwater: rda 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.) Na PRIVY: (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) rds (revised 04127ST) G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Kathleen O'Neill:128 Pleasant St Bass River South Yarmouth 02064 4124198 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) rl � qQ �ll op o �b DP (revind0427197) Pays ! o! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 217 Prince Hinckley Dr.Centerville Map 171 Lot 113 Kathleen O'Neill:129 Pleasant SL Bass River South Yarmouth 02804 4124199 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 (nvludOAl27197) 1�q� 1t0 0[ 19 �71 LOCATION �t'/ /'J SEWAGE PERMIT NO. L.cA,4i?,l ?S - �� I � VILLAGE "�� INSTA LLER'S NAME ADDRESS S U I L D E R OR OWNER ` DATE PERMIT ISSUED DATE COMPLIANCE ISSUED iL C.ot $ l F�ar� � —r� TOWN OF BARNSTABLE LOCATION C tj SEWAGE # VILLAGE 0 ,5.�•a t l® AS SE SOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t®oo 5 Fy LEACHING FACILITY: (type) �� � (size) NO.OF BEDROOMS 31 n BUILDER OR OWNER PEjdvffq�,DATE: � \ �i COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and E, �1 Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) �� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) . Feet Furnished by -3cb L0 AfON SEWAGE PERMIT NO. e i -e 7 : yl,(icse4 E y W2? VILLAGE IN.STA LLER'S NAME & ADDRESS B U R D E R OR OWNER 19Z,VA✓ 51PAJ«i-7-Ne- Toy 34 CF/y/ 5 GATE PERMIT 'ISSUED y f DATE COMPLIANCE ISSUED 7 ,. ,.„ a �� � � , _; �� ��� i v �� r 17�- /1, Nc F:m ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR- D OF HEALTH e.0 M".""................OF. -7AVV11ratiun for Uiupuual Works Tuuitrurtiurt ramit Application is hereby made for a Permit to Construct (kor Repair ( ) an Individual Sewage Disposal .._.qa 6 <.�__JE`(-•.0�..:. aa�c 2 o�-� ................. ......................................... LocatOwner ess ......or Lot No. Xv::.:.. �otr z°add �t .......... .......................................... Address aSrJ�..... .......................................................... Installer Address Type of Building Size Lot?-93.2?T5------Sq. feet U Dwelling—No. of Bedrooms......_.3................................Expansion Attic '�� Garbage Grinder Other—T e of Building .............. No. of ersons..................•..____.__ Showers a Other—Type g -------------- p ( ) — Cafeteria ( ) Otherfixtures -------------------------------•----------------....--.------......--------------------•----•--•----------•••---------•-•-•-••------------------------ W Design Flow...._... 5..........................gallons per person per day. Total daily flow....... -. ...-........-........._..g llons1. WSeptic Tank—Liquid capacity- .gallons Length&i nG.. _ Widdth1-.10. .. Diameter....-_. ....... Depth�-'�'___. x Disposal Trench—No..................... Width.................... Total Length-.--.............. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter...1............ Depth below inlet............... Total leaching area.269.7_....sq. ft. Z Other Distribution box Im Dos � nk `1 t aPercolation Test Results Performed by..' _is ___�_�.ET_-...1 k-:...... Date..9 �_ Test Pit No. I.....�- minutes per inch Depth of Test Pit-----�.�......._ Depth to ground water._bNPTA0 Lxxvw& fs, Test Pit No. 2................minutes per inch Depth of Test Pit...... 4........ Depth to ground water-------t i __ 0 TtN:7 . -... Description of S it _' ... �,fi?ro.�a.�. ........ o c L....z'� 1 U ---•--•--- -------------------------------- ••----•----------•------ ------- 0 rZ l '�v`��i 5 "�� � `t? �7---1 ti -------•-----•-•--•--.... 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 TITLE 5 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 the board of health. i Sined...................................... Application Approved By.........•-................................ -----.�._P - a7�� Date Application Disapproved for the following reasons-----------------------------•-----------------------------------------------------------------------------....._ u Date Permit No.__ f .. Issued-.....-..................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .._................ ....................OF...-...... ct...... Appliratiun for Disposal Works Tonutrnrtiun rrntit Application is hereby made for a Permit Itto1 Construct ( or Repair ( ) an Individual Sewage Disposal 5 .....5 8�L \``........ •� �4�� I LLC; -�' _._ .........................................\. . � Location•—A......s or Lot No. •-- ......-T--`-`---`• t-��-��,- � �......... ...........................•----..........-----------•----.....----- ...---......._. W Owner Address Installer Address U Type of Building Size Lot.-Z-9, Z6�?.._.,Sq. feet Dwelling—No. of Bedrooms___----_.3...............................Expansion Attic Garbage Grinder (uO aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther Mures ...._._..-•--•---------••-••---•------•...--------•--•----•--------•-•---------•-...---...-•-•••••--•-•-•----•------•--------•-•---------------------- Design Flow........��................................gallons per person per day. Total daily flow-_-_- -�.......... lonsl W - ..........._ R: Septic Tank—Liquid capacity..�.�gallons Length-5.-.G.."Width---A f . Diameter____- -___ D(pth._ .- ... Disposal Trench—No..................... Width.................... Total Length_ __..___._..___. Total leaching area_____---_--.__--____sq. ft. Seepage Pit No-----------------_-- Diameter.._.NC) Depth below inlet............... Total leaching area_Zk ...sq. ft. Z Other Distribution box Dos�ng_t nk (k,�� _ a Percolation Test Results Performed by.._T?=`-� :: ._.1 _ _V.__.�!�_�-._____ Date___ .......... Test Pit No. 1................minutes per inch Depth of Test Pit......U_ ........ Depth to ground water-__t`-+� 4 Test Pit No. 2................minutes per inch Depth of Test Pit......�'_....... Depth to ground water......... �__...---___ _---- -•-----------••-------••-----••- ----•---------------- ---••---•..._..-----••--- x Description of Soil `---... « -u 4 a ©'_�.------�--- t`.s'- --4g... ... .�? ---•----------- ----------- � --•---•-------------•-----...----- - ---- ----------------•----- ---••--•-----------•------- -1�-..-i---------- `--'�_-• q`k`-`.t- �:+� `le i �. _--�--- -` �,.J 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 TITL i, 5 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 the board of health. Signed....................................................................................... Application Approved By..........:�.�....................`.....t � ++ ...............------ ............... Date Application Disapproved for the following reasons----------------•-----------•------------------_................................................................. ��---^ Date PermitNo......................................................... Issua....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................OF %T�rrtif irab of Tontphattrr THIS If TO CERTIFY, That the Individual Sewage Disposal System'constructed ( ) or Repaired ( ) by..............T. ................................................... ............................... 11 .. Installer . ---- has been installed in accordance with the provision T 5 of The State Sanitary Code as desc ibed in the application for Disposal Works Construction Permit No._.__._.��.5-_�. ........... dated-.......... L- ����._..---..._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL jFYNCTION SATISFACTORY. DATE............:.. - �' ....................................... Inspector................ �7?........................................... THE COMMONWEALTH OF MASSACHUSETTS Q BOARD OF HEALTH O9! ...........................................OF...................................... ......_... � No.................... .. FEE... ... Iiu uu 1 hs 'o gnutrudiun rrutit ._ Permission is hereby granted L� .-----------•••-................................................................................................ to Constr,ct or Repair - ) an Individu ewag ispos S stem LaF !3 co - .........................................I �- � ................................... r Street as shown on the application for Disposal Works Construction Permit No. Dated......1.0 J 3 l I GIC ....................................................-----.------•-----••---... -••------ DATE. Board of Health ,� FORM 1255 -HOBBS`& WARREN, INC., PUBLISHERS - f _ICES/G/t/ 14 42AZA L4nACt L%7A,Mi L,� -3 cS1=vgcoMs KiO G k7%,5 .6cE =t��N�SQS Cyr=C VsF- 10oo QA-L eLA-TkIAV, �IS�05�•L i�iT�^ C.1SC lObb�s W 2� S'�►.tE • • $�p6wgLL ; Atr.A 168 sV Ck?u-uty t68 CZS : q?o r«P P �o�t►IL �ZEza. Z 9 ?9 Q4 7 L"P SAS •1'oTAL�I rl t L�(�'uO v�! 330 C,�P'D • -D Sl�c�t FGZC-ou.-not-k ?-ATa ; 1"'��oP »► 2M.�►.1►. �P��N OF Mgs� �0�,�+ . PFTER RICNARD VG� _. o SULLIVAN A U 6 BAXTER No. 25233 No.24048 I.TV N TEST f/a�E S � DODO /yam BOX /rV✓. GAL, 6n�to►•� .. 51 O 51•C� .SEPrrG 1 �' Im/. /Nc! G�u4Kao '' SI,2 51'•q c�,E,eT/F/EO PGOT p44A/ ' sTbu= •• 9 �" �A0 1� ►.� 10 / GE.er/,CY 71- 4T'7;VE~_moo v►..�r4�cx lS.ya w.t/ A�vI>.SET�/1 G� ,e�4lJ/.�ENI�iNrS d f Tiy� Toxin o _ ,e,EGisr�.ec-I,Gavo slie yEya,P� ILL�rl e, T//ls��it/ /.t �YoT r3.4fE0��v ASV/yST,Q- S/�l�iv�/E,2EarV S.4�oU�-I�ypT!� USEp �� Igy 2 � k4C �r 1 2 99 2Ga .6F 36-z 7/ i ' 23� • \7 ' 05-11 TH OF 4q ` o���P� �SSgcyG j�iH OF m 4 I Co SULLIVAN yti RICHARD , No. 29733 A' o BAXTER CA E40 �� v Na 24048 FSSJpwRt F