HomeMy WebLinkAbout0253 PRINCE HINCKLEY ROAD - Health 253 Prince Hinckley Road
Centerville P
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TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection RWqYfiP,3o(�
19 Hummel Drive I!i
South Dennis, MA 02660 S E P 2 5 2003
COMMONWEALTH OF MASSACHUSETTS TOWN O�BAR
HE
EXECUTIVE OFFICE OF ENVIRONMENTAL A
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Proper(} Address: 253 Prince Hinkley Road
Centerville, MA
Owner's Name: Anna Kenney
Owner's Address: 117 Wooden Carriage Drive
Hockenfffm,DE 19707
Date of Inspection:. September 23,2003 0
Name of Inspector: 'Troy M.Williams
Company Name: . Troy Williams Septic Inspections l\ 11
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system-
✓ Passes
Conditionally ['asses
Needs Further Lvaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 9 Az 3 /U 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This Inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the saute or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 of 11
Page 2 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any 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:
One or more system components as described in the"Conditional Pam'section nee o be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the and of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the for the following state nts. if"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic to • whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failur s imminent. Svstem will pass inspection if the
existing tank is replaced with a complying septic tank as approve y the Board of Health.
'A metal septic tank will pass inspection if it is structurally so d,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 br ut or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle r uneven distribution box.System will pass inspection if(with
approval of Board of Health):
ken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syste quired pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection' (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
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)( that the
system is not functioning in a manner which will protect public health,safety and the envir b nO t:
— 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 mar
2. System will fail unless the Board of Health(and Public Water tier,if any)determines that the
system is functioning in a manner that protects the public health afety and environment:
_ The system has a septic tank and soil absorption syst (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water su y.
- The system has a septic tank and SAS and c SAS is within a Zone I of a public water supply.
— The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". M od used to determine distance
"This system passes if well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile ganic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteri a triggered.A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address.: 353 Prince Hinkley Road
Centerville,MA
Owner: Anna Kenney
Date of Inspection: September 23,2003
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
_ _4L 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''/:day flow
✓ Required pumping more than 4 times in the last year VQT 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.
Lv LiAny portion of cesspool or privy is within 100 feet of a surface Ver supply or tributary to a surface
water supply.
&,jLj Any portion of a cesspool or privy is within a Zone 1 of a public well.
tim Any portion of a cesspool or privy is within 50 feet of a private water supply well.
j Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
No (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 esign 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 feria above)
yes no
the system is within 400 feet of a surface dr' ing water supply
the system is within 200 feet of a trib to a surface drinking water supply
_ — the system is located m a nitr n sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped
Zone 11 of a public waters ply well
If you have answered"yes"t y question in Section E the system is considered a significant threat,or answereO
"yes"in Section D above large system has failed.The owner or operator of any large system considered a
significant threat und. ection E or failed under Section D shall upgrade the system in#cccordance with 310 CMR
15.304.The syste or should contact the appropriate regional office of the Department.
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Page 5 of I l
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
353 Prince Hinkley)toad
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the followine•
Yes No
P:;:,ping information was provided by the owner. occupant,or Board of l iealtl,
✓ Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the.system recently or as part of this inspection?
— Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ _ Was the facility or dwelling inspected for signs of sewage back up
✓ _ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on.the site has been determined based on:
Yes no
✓ _ Existing information. For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
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Page 6 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of inspection: Anna Kenney
September 23,209LOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Nwnber of bedrooms(actual): .3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 o
Number of current residents: O (z 13.- )
Does residence have a garbage grinder(yes or no): Na
Is laundn on a separate sewage system(yes or
no):-[if yes separate inspection required)
Laundry system inspected(yes or no): A,1A
Seasonal use:(yes or no): nio
Water meter readings,if available(last 2 yearshsage(gpd)):o = G 6 o o u �,,h a t = 6 3,CVO
Sum es or no : �Sump (yes Y to) _
Last date of occupancy: i , p 3
COMMERCIAL/INDUSSTRRIrAAL1-
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 sy m (yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: A/ r.�,...
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—Privy
—Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank ,Attach a copy of the DEP approval
Other(describe):.
Approximate age of all comp�onents.date installed(if known)and source of information:
p
ad / � 4 ( 0.� re Sti41 11. L..a r.� a-,A Lt`.c-L.
d JH�8 6 P. _ a.,-bL,: If-,
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
BUILDING SEWER(locate on site plan)
Depth below grade: 1 e "�
Materials of construction: _cast iron ✓40 PVC ✓other(explain): It) 6+- Ju }-,, Pv`
Distance iron-,private water supply well of suction line: Nt1
Comments(on condition of joints, venting,evidence of leakage,etc.):
J h c G✓ o N Y.s__p-c C.. J a�
SEPTIC TANK: ✓(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass_polyethylene
—other(explain)
if tank is metal list age:_ Is age confirmed by a Certificate of Complianc (yes or no):—(attach a copy of
certificate)
Dimensions: 5'k- ' r /000 s II)
Sludge depth: ye,
Distance from top of sludge to bottom of outlet tee or baffle: '8''
Scum thickness: IV&NL
Distance from top of scum to top of outlet tee or baffle: Ato s
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as rllated to outlet invert,evidence of leakage,etc.):
'_I«s �`.1tr< � �O✓l'�, ..,� Oy�tiv. /�.� .-GJr c�s.V�L< q./_-..�t�t.�y.�.c. c�v alc..�•.o-.yt
✓J" 3 9��r l'. . k- 5 N o 4- d, c_,e-
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass yethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of outle a or baffle:
Date of last pumping:
Comments(on pumping recommendation let and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of age,etc.):
7
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiber s_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo%%: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working der(yes or no):
Date of last pumping:
Comments(condition of alarm an oat switches,etc.):
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 carryover. any evidence of
leakage into or out of box,etc.): �1
cam / ✓�
/lld
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,conditi of pumps and appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,MA
Date of Inspection: Anna Kenney
September 23,2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why
Type --- -----
leaching pits.number: of - (o ')CC' L-,,L,
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,
et'c.):1 / �/
( c� c� we 3 �O c.J h11 lOo 7F c/.��� //I� ► 1 c,4-O <..� N ....t 1 ) �V�t✓w-V t a. T� I✓VL L✓ � i��C.y1.
1 I L /J4.S T •JI'�^ /4�-�)." ,�• S ��+n.c. 6J t. S I f &� Lto
b►r (r./�,rrG-.n.+ O to /"t-• 71 ?'1JY^� _
r.ss G. ..�i�'I�ti s o J� �t�-�-(..t� o r � S YZw•.,.CESSPOOLS: (cesspool,must be pumped as pan ofr inspedtion) ocate on site plan) f y
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
Comments(note condition of soil,si of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydra7ilure, el of ponding,condition of vegetation,etc.):
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Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 353 Prince Hinkley Road
Centerville,MA
Owner: Anna Kenney
Date of Inspection: September 23,2003
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.
toor��
13c--c,r,-.
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Page 1 I of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
353 Prince Hinkley Road
Owner: Centerville,NIA
Date of Inspection: Anna Kenney
SITE EXAM September 23,2003
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water S feet Adjusted high ground water elevation
Please indicate(check)all methods used to determine the high ground %%ater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Ilealth-explain:
Checked with local excavators, installers-(attach documentation)
✓ Accessed USGS database-explain:_S p ✓ z S- z 2 O,v, /� y2 3 0, J
You must describe how you established the high ground water elevation:
` ' Z C.ti,A W 4 F-a.✓mot •G-.1 t,✓:�-?�:a Z.Z 2
Gn.
J V u
3s '
This report has been prepared and the system Inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees, either expressed,written or Implied,relating to the system,the Inspection and/or this report.
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