HomeMy WebLinkAbout0382 PRINCE HINCKLEY ROAD - Health 382 PRINCE HINCKLEY ROAD
Centerville 1
A = 171 - 176
i
R
i!
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner information is Owner's Name
required for every Centerville V MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information 45/# MSY f
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
QU41 A6 3/20/20
Inspectohtignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
i t
Commonwealth of Massachusetts
r= ,.? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�o
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. CityrFown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
L
t
I
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3 Further Evaluation is Required b the Board of Health:
q Y
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form'Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone li of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth,of Massachusetts
�= ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 18
I
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. CityrTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Engineered plan on file at BOH
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 260 GPD
9 ( Y 9 (gP ))�
Detail:
Irrigation at property
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner information is Owner's Name
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Pumped 2018 per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c°" Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1985 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owners Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 20"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, it is under a cement paver patio
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth:
8"
Distance from top of sludge to bottom of outlet tee or baffle
>12"
Scum thickness 1/4"
Distance from top of scum to top of outlet tee or baffle
>2"
Distance from bottom of scum to bottom of outlet tee or baffle
>2"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L � 382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
` Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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.):
H-10 D-box is 2'6" below grade, no adverse conditions obsreved
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
off, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.1/26/20111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u 382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was video inspected, effluent level is approximately 4' below the invert at this time, no
indication of past hydraulic failure, cover raised to 12"of grade
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
pi
�V
t
b
C.3 1
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
,. lq Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >13'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 1985 NGW 13'Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
4'seperation per 1985 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Site is at 52'msl and nearby surface water is at 34'msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinkley Rd.
Property Address
Gardner
Owner Owner's Name
information is
required for every Centerville MA 02632 3/20/20
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
ti
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38
—2 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner owner's Name
information is 'Centerville MA 02632 04/13/14
required for every
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out fortes A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your I
cursor-do not Kevin Cochran I � I
use the return Name of Inspector
key.
Aardvark Environmental Inspections
�y Company Name
P O Box 896
Company Address
East Dennis MA 02641
Cityrrown State Zip Code
508-385-7608 13356
Telephone 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 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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs F aluati by the Local Approving Authority
r
04/14/14
I nspectO?s-§jdwjfure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
""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.
t5ins•3/13 Trtle 5 Official Lhspecrfi : aoe Sewage Disposal System•Page 1 of 17
Commonwealth of assach gee
` IT
I rtie 5 Officnai inspection t'orm
.'.e S�... .-€''-.i 1 y Assessmenis
'„v 3082 i,iiii ie 11 iincidley Road
riuvelty nuwv_ib
Aiir-p nPniE aiPirrin
v`ii mer Ovme-,'s Name
information is reaired avreverV `e`} ry eie r4A F?^a2 = 1. -
2
:e —apage. t Z- l_tS - ft... rtL`ME�'-^
iii;pelr;-on Stluiiliiip �i_%iI1,n JS,%r,u Vi i_1 p w"p7�'y"Ea�.V iii�I Oit vi I7eetio v
Al
System Pas-=e—sm£
(� haveno.} rs icy 3r ii�ffr s^Lt sg niC!n i11-= 3c si E!:MV r*�;a iII-Ire M-8-ria e±; ribb
.;.:,71�.: i :is M. .:4�Xi-Si. Any is re t is va e.2ll.ated are
indicated begow.
Comments:
8) —*Ysft,-n co. "fl-Onal1v Passes:
-eer r - ve'^ ^ ti"s*sy ^ sn.z � e � . F r : -y ^
r�riS1'ii=.-yr repaired. i he 3 3leii 11Pon co :�iivu+ii ai ii�Y.v�.wita.iii v�r �iY.ii, u3 GiiEii a i„iy
the Board of Health, will pass.
T d Y' TY ti N d d-
A s7:+.`. ..s.�ae1 6 4 i
�„�������'�sl`�.; ="`� sab�i"�i�t _-�e�6'€�i:.� [z, i� p :�. �.e ii.._�ifi����cs€.aa;:S. .. -a'it4t
cetera 4 ai!leo,"please explain.
TL... ..... "-I. :.. ..._4_1 --. ......�"'PR .. ..i.Y3 -�:.... ., ':...3.....L. i».C...dE..-�.._-G..L�..___'I d.......:..
li-' "PLR.iC.Hfl.to ii i-_L�i ai U VYLi Z-U Caa!O UiU t00 lii\.3l.^CLCa Laiifl kiwisual si. cric;ias uj iiiji it$.3iiid"utuwaioy
1 Ills lilrr/ J � ti � j
-.R +rfe 1.9iy,.. 6. + ,. -.. ar5� ;,� . lsi`4tr 1-__.c R 4cf ana-E•rig -.ic4? <<
iS ._v. €_ _ 5 .._. e.: r'.i v' _=.S.0 Mc Jr ..n . ..� i :' e air=e=:F � es i i Fc?«
nspe"—Ion if 4i-ie exisiIing. 'calnk is replaced w h a comp-irig sepi -€O.rik as app :Ved by the Board of
A rn. i - _ s`v tank v L " � 41 i 4<i�. - 'a` S-oti ; riot an a er t`3 e'of
��s i--- � r�i� �� $3r ii= ;3tleaking �-�4��
nc
Li
'[
Tide-;;Offi=^ ;3..,.�ss"'MFA.:.:...--P7.:�.�_S s� �?:3p8 a:i�^..S&2 S�t�m•. .--_'�
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Plilince Hinckley Road
Property Address
A!ice i eg giiieimo
awner Owner's s dame
information is Centerville l�A 102632 04113f14
reruiredi for ever.,
page, vEi:l EE Carat �Late 'Lp Code Dame of inspe€ton
B. Certification (cont_)
El €Krat ajer.�,or:ni /�uiarri'm 8?C°truti °EAR, System will mac isa;t "^ ar of`Iaa€#r, arir :ral
pu ps;alarms are repaired.
B) System Conditionally passes (cont):
❑ Observation of se''J ewe rbacki-1 or break out or i!-h static-ahlat r ie rel jn thr_odic„--i but ion box rills
to broken or obs:ructeOa pipe(s;or.due to a broken, se-tUed or uneven oistriE ution box. S stern will
pass inspvIkA-1 3n; kiwi`t appiovaal of-Bow'd Of r iF-a±th):
❑ broken pipet,s,} are ren-lace ❑ Y ❑ L�° ❑ 4i1 LJ(a-xpial9! 'elow).
❑ obstruction is removed ❑ 7 ❑ N ❑ D ttxplain beioww :
❑ d aistri-bution; box is leveled or repiae-era ❑ ❑ ❑ ti J f=xplain -raelOri;:
i
❑ The s stern required pumping; rnore than 4'imes a wear due tn- broken or obstrEuicted ppipe(5 . The
system will pass inspection if(With approval of the Board of l-lcait ,j:
❑ broken pipe(si are replaced ❑ `t ElN El vI) (Explain below),
❑ obstrsiGtia_n is reRl?Oved ❑ Y ❑ ti ❑ NE %Explain i"ielow-.
13 Evaluation is Requires y =ti
!r. tl:�.°8�€'C�ti.iSE�=�' _.� �� the °.g-ard of He'r}64!?8:
: , l et^onditi?s oxiet icy r � ir `frlPr_: l etor v ®firarfit r# �a ti in ri r# �rrir
if
the sysleri i is c^aiiinc to protect public nealtn, satiety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
ming to a manner= lch xill protect ut.?ttc health,
safety es `-w-he environment:
❑ L/VJSipi-le'1 e; privy ;+�i. -with— V- iLVt o a VL¢::ac_e evar :
El�i y �. .E or ns _�r» - �e t r ^rde , >_rc� •`.{... ii-�-��i or -rr� srs
..awii`oo-o p. ,r ;v :i�ii"ii, vV i. - a =v:..ev'ina ervet Eeu -eiiand o a sa-11:
5 G-nda.,a�-a"-.tp r. �'iFL ,;ha..s.� �0:,"= -r=„fie rt,� m_o g_3_f 3.7
Commonwealth Of Massachusetts
CUUtiurvan„ ct-nCtut:umpu-var c-v? Sa_n ESm E-Q nvi g40 e, , tiu;'�,E ndiy-'tbt- vL--titim!tm
v
=Is'45tnE� tt,.m��r ILInrrr,
informatienis y ,,.. ILEA n7C:•1 f%A14"314A
ar m�irs.t9 fiye .;n�jj,+ C-e,itei 411fe et�lfi SJGV.3a V'43!-IX it
Wage_ Cl'iyi113i�i1 $fiarB Zp Code Rafe 01 inspealor,
z_ System v eti faet unless brae Board ua Heal?�6a land Pui�inc Water Supplier.if
detemOnes Mat the vypstern IS fungi nning'In e Ynanner that umutects the public health,
sarkt 1 and en$ikonment:
❑ The system has a septic tank and soil absorption system (SAS)and'the SAS is within
?00 feet of a surface water suopty or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone I of a public water
suppiy.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply weil
❑ 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 weir i.
Method used w deterrmine distance:
_ h,>sysiem r�se_s if gie. =??+1,R = _;f;>z, r5re, ? ",r,_. uabo€^-st , i rfrg s'!
* M � t ,sg s'Pj e ,resence of ammonia nitroq-en and nitrate nitrooen is equal
to or less era`)vpm,provided that no other taiium feria are trpaered. A aO P!4 Of the anaiys6s must
be ad—a-c-hed IS Jffl_
•i il{Y4Q�_
wtwil s_s
��4e��k=€r�T�e+����K.P.`loag�@e�= in--
Yes
?ar 9➢' F ; E+e8�&StF ie$$44i 3iXrri86-��r 4� lea)
No s
❑ Backup of
se vaae in,---facifit,or system component due to overloaded of
ViiiV�lrrY VliV VI iAiJJ�iVi%I
❑ N
U€" eei;a3¢.I,...�='Pt-..aa u4s.: ----.vtls,.u° +:.L:i':-r.i€n �.sl:.. ,r t=a . ov ,e.,+cs.aed
(_ _ �:t:€:i>�S.1el:1 iZ5 s ire �:€ o0i
Li i.:€r° a `! rt raecr o ,_! sF ^." hcls _ sue+ rr r.` , ,I h', �y;: r^, -s:a«
ll. r 9/ J� .LI in S wr-_ .vvv t „n y kv•v - .ee 4=
VOY
t5 _,fi3 Trio 5 i tee. I hs ...... C rfsewwe lammn-_" Pa..e 4 of 17
Commonwealth of Maa¢achuseti
SulEr®faee re rage Dispos-al System Form_Not for Voluntary Assessments
.++ '82 ''nnce Hinckley Road
vroperiy Address
Alice Deguglielmo
Owner Owne's name
information is
required for every Genteryiile MA 02632 04113114
page, Cit:T:.n Mate Zip Code Cate e;insp ction
v. we. �ia®vaa i.i6isi ``vvii.f
Yes No
❑ iDi i°fret pumping trot¢then `s tries in the iagt yea. due to clogged or
obstructed pippe(Sf. Number of times pu peu:
❑ Any portion of the Srftiv. cesspool or privy is below high groun a water elevation.
❑ ® any nnrtlrsn nr'Gesgp�srsl car pn�v is�e✓ita �)�r'eeg of Surrace water Supply car
triuutai i to a surface water supply.
❑ Any -iortion of a cesspool or piivj is within a Zone `i of a public vdeil.
❑ ® May por%IwoI oe a c S,;;,1 or irriVy iS vditssii6 vc7 feet of a private vdater SuprpiI-`vVeii.
❑ ® j'ny portion or a,eSCrfo_fi or p_iU� Is ieSS than 100 reec outrRafar than ?C feet
frosin a s_:.rivate¢dater su-+piy well,with no acceptable water quality,analysis. e hi13
s � :asses iif thw we'i wati;i aiiaiyse3,port v iritG at w Dea +vC®—aioie d
laborato
,V®for teal:colfform bacteria indicates absent and time Renee
of ammonia of rom3en and nitrate n1t gen is equal to or less than 5; iwap6.i,
provided that no other failure cuter€¢age tea s_A--- v f the-
and chain of Custody must be aftached to t Ims forms]
g
❑ Vi T
❑ ® fi g Via= x _ ,_ ir.r ed le hat nine slr or of s:r_abovevailur= '.
..44-...�.b- i kuz�..,+ z,
E 2pEC�.y�6•3� ea. -"R F�2^ �h'.'K-z RN'; 6� nTPaei..SSG�Etz B€OT��,5��:3£4?
� -_
i=rss 9a;rss+cuct amS vn�p mpsst anrt;a �ii#� r° q'or y€;nb to each of the fnilnwinr; in Ali tine#n the
in
Yes No
El
<t � :?`r_ � y ,�d�=tE. 3: Section = Sy teM.I aS taons! leamred a sign::°rand threat,
IT
at
sysram,oon' iiered a si 3ai �l Inre 3+ai[er aE 3ss L Or MHP-0 Un43*r Zj6C i;i U Stet 3 x"s=aDa`iaMEMS,terse
M Mink
maiiana,aiiice rr 4€e i¢-Senn€€.era i!_
r4-r.c._V,S Tilly 5 Offic ibe Can;4r P' 5�41,'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo_
Owner Owner's(dame
information is required for every Centerville MA 02632 04/13/14
page. Cityrrown state Zip Code date of inspec con
C. Checklist
Check if the following have been done.You must indicate"yesp 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?
® ❑ 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 t!:e Sol!Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to fart C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
' 3
Number or.be'dr�.ncms(des n): f-umber of bedrooms(actual);
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
tlinr.3113 r_k*E,Offidd L_oo=r—F rn_tbs Sk—eae DmpliSal 4y_,-r_e_m-Pee 9 17
I
Commonwealth of Massachusetts
Title s official Inspection Form
Subsurface Sewage Disposai System Form-Not for Voiuntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner owners Name
information is required for every Centerville MA 02632 04/13/14
page. Cityrrown state Zip Code Date of inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes E No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
p �' Date
CommerciaUindustrial Flow Conditions:
Type of Establishment
Design'flow(based on 310 CIVIR 1 s.203): Gallons per day(gpd)
Basis of design flow(seats.`persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3H 3 Title 5 Offictal tnsgeMm Form:Subufffa a Sawage Disgesai System•Page 7 of 17
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice veciumielmo
Owner Owner's Name
information is required iur PVC+y Genterv'ille MA 02632 04/13/14
page. Crry�r v= SYalle Lip Code mate of inspection
a. Oyfeir infOlfm ®®I!i icons.
Last date of occupancy/use: Date
Other(describe below;:
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined%.
Reason for pumping:
Type of Systems:
Septic tank, distribution box, soil absorption system
Single cesspool
❑ Overflow cesspool
❑ Privy
❑ shared system (yes or no) (if yes, attach previous inspection records, a any)
❑ lnnovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the OEP approval.
❑ Other.(describe):
t5i:s-3173 Tfle 5 O!fi�l!Rspectm Fare:S bsudsw Ss.-age Dispose-1 System Pays 8 of.17
Commonwealth of Massachusetts
i me ttici i inspection i-or
Subsug-ace Sewage 0-1sposai System Forma-Not for Voluntary Assessments
z rv—V 38-2- rrince Hinckley Roar
Property Address
i E ice D�.S'i i<ylia®.Iri
Owner Owner's!dame
information is Centerville MA 02632 04113/14
required for every
page Licy;a awn slate Lip i oae Daaie of inspecuon
D. System information (cunt.)
Approximate age or all components,date installed (if known)and source of information:
U5ru3i85 per 80H -- --
Were sewage odors deiected when arriving at the sites ❑ _p es ® No
Building Sewer(locate on site plan):
LJGFiGi i tiGEiILiP .C4iiG. fee_
t
!f f
Material of construction-.
❑Cast iron ®40 PVC El 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):
1.8
Depth below grade: feet
Material of construction:
Z concrete ❑ metal LD fiberglass ❑ polyeihyiene ❑ouner(explain)
years
is age confirmed by a Certificate of CompiiancO(attach a copy of ceriffiicate) E Yes El No
Dimensions: 1000 gal
K:
Sludge depth:
t5ins•_VI Title 5 ofrr- i hspeclon Form.S rf Sewage r�sposar System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
klv,i�tw,i- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner me's Name
information is
required for every Centerville MA v2�s32 04/1 3/94
page, City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Septic Tank(coat,)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Cr+nrr°4hinlrnQec 31'
Vv4°°• V°°V°\IVVV
Distance from top of scum to top of outlet tee or baffle
5'°
Distance from bottom of.,ct:m to he-& m of-utlet tee or baffle
How were dimensions determined? Measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition; structural integrity,
liquid levels as related€o outlet'invert,e:rdence of leakage,eic_):
The tank was sound and tight with tees in place and liquid at ou►1e1 invert-
Depth below grade: ,e,
Mi atvrial o-cons ruc lcn:
l_t E:vi ivi ate. {J eic3ai� �:iiuca cgg,—QS-Q lj PO GU a V IOv iv � Vkl a tcsii.iaie r j:
!A i e zsio.ns:
Scum thickness
Di! tianice Ef illFt t4P Vi 4L.t?6Ff t+tUP W ;)t=t6 t fi-P f-f i3 —1;
Distance from bottom of scum to bottom of outlet tee or baffle
Cate
3113Tige 5U.fiaal'£ Ear:S= SvimasgaMspaa-`,.p_.em-Page'Oa 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form a Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner Owner's Name
informations Centerville MA 02632 04/13/14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System 9fiforrratioln (coat.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight of Bolding Tare(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction.:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.3113 Tale 5 Official hVection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner Owner's Flame
informations required for every Centerville MA 02632 04/13/14
page. c4rrown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Sox(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Even
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_):
The box was level and tight with no sign of carTvover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc_):
* If pumps or alarms are not in working order;system is a conditional pass_
Soil Absorption System(SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
t5ins.1—M3 Title 5 CdNrEd inspecbm Frnr:c.&—Tf_a Smogs D:rusal Sygdn.gap 12 Ls 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner Owner's Name
information
required for every Centerville MA 02632 04/13/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (corn.)
Type:
leaching pits number:
1
❑ 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.):
This system has a VxV precast pit surrounded by 2'of stone.There was 1 T'of liquid with a stain line
6"above the liquid.There was no sign of ponding or failure.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ms-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner Owner's Name
information is required for every Centerville MA 02632 04/13/14
page. City/Town state Zip Code Date of Inspection
D. System Information (corn.)
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.):
t5iru•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Police Det;ualieimo
Owner Owner's Name
information is required for every Centerville MA 02632 04/13/14
page_ City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply eaters the building_Check one of the boxes below:
® hand-sketcl o in the area below
1 ❑ drawing attached separately
i
rear
10
10
30
36
24 22
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
382 Prince Hinckley Road
Property Address
Alice Deguglielmo
Owner Owner's Name
information is required for every Centerville MA 02632 04/13/14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water. 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show anelevation of over 20.0 feet.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official trtspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 382 Prince Hinckley Road
Property Address
Aii vcyiigiici�iw
Owner Owner's Name
information is
Centerville NIA 02632 04/13/14
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection.Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official hmpection Form:Substnface Sewage Disposal System-Page 17 of 17
L.00ATIO SEA SEWAGE PERMIT NO.
3 -
VILLAGE
-
�I._N...S_,.. LLER'S NAME & ADDRE S
e UILDE R OR 'GINNER
, DATE PERMIT ISSUED -Z
DATE COMPLIANCE ISSUED s g�
�a.���
3 � � � Porc►�
�p '� e..
3° a ' :��'�- '
��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALtP
....o!.*..�s-�-........0 F........ ....................................
Appliration for Uiopoottl Work.5 Tonotrnrtion amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
`
....... ... ..................•...... .......... . . ...................
ati .Addre •-• — or t o. 0
.....................•.......... .......... .et-... :._6.�Gc�....................... ... ..... ..... .... ..
caner Address
.................................... r............_........_.....
Installer Address
U Type of Building Size ....Sq. feet
., Dwelling—No. of Bedrooms............................................Expansion Attic ('41 Garbage Grinder ( 04•b
aOther—Type of Building ______________ ____________ No. of persons.............................. Showers (,sep— Cafeteria (kb
Q' Other fixtures
........._..gallons per person per da Total dail flow__._...... 97 9!+' ........__ Ions.
w Design Flow...... g P P P Y Y
Disposal Trench tic Tank—Liquid No capacityt.�'' adlthns Length Total Lengthidth..............Total leaching area Depth......sq.ft.
Seepage Pit No.....LOX Diameter.................... Depth below inlet.................... Total leaching area.... ft.
Z Other Distribution box ( ) Dosing tank ( )
`4 Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_............:........
Pr'
Descriptionof Soil........................................................................................................................................................................
x
w
VNature of Repairs or Alterations—Answer when applicable................................................................................................
----------------------------•-------------------------------------------------------...........---------•-------...-----------------------------...--••----•----•••-•-•.._....--••-.....................
Agr ent:
T e u ersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
e p , 'I, or o I I LE 5 f the State Sanitary Code— The undersigned f ther agrees not to pla/thyste in
o a� r of Compliance has been is e by the
turd o ealth.
Si ned �"'....... .. . �'... . '..
p is on Approved BY- --------• .. ......-•-...••-•........................
._�
Date
plication Disapproved for the following reasons-----------------------------•-••----.........-----------------••----------------••--••----:..--•••-•-•....--•--
......................................................................................................................................__......._........_...Z........__............................
Date
Permit No:.....V...`.'.-. 4.3---------•--------. Issued........:•�v--- ----� -� -
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
P -
.....• >
Apli ira#ion for Uiipooal Workii Tomitruriion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
r ................................:....................•--...--•--••---.....•--....-- ..........:.....--•------------•-._...•----••------•--•-....---•-----------•----.........---...
Location-Address ��" or Lot No.
Owner Address
...... . -• '-......................C.-. , f................................................. ........... .... .. .......................................................
Installer Address
UType of Building Size Lot.. .. :.:.................Sq. feet
Dwelling—No. of Bedrooms...... _-..............................Expansion Attic ( ) Garbage Grinder ( � )
aOther
—Type of Building ............................ No. of persons............................ Showers (�'- ) Cafeteria ( )
dOther fixtures ------------------------------------------------------......---------------------------...-----------------........
W Design Flow....................... gallons per person per day. Total daily flow...........:. ...:...........::..........gallons.
WSeptic Tank-Liquid capacity!............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________;_____-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
L>~ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•---•-----•---.....••-•-...•-----•--•-----•--•-------...--•---•----•-•---------------------------•-.........................................................
0 Description of Soil......................................................................................................................................--------........................
x
V ............................................ -------------------------------------•--------••--...__......--------•------------------•--•---•-•-•--•-•---------------•-•-------•--•-•-----••-•......----
W
-------------- -----•-•----•---•------•------•---••---•••---...-•--•-•-•------------•--•------•-------•-------•--------------•--------•--•-------------------------------............--•-••--•--------
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.............••--••---------.........._......-•-----•-----•-••----........_........---••--•--._..................-•---------...-----•---.....................................------.....................
Agr ent:
T e un ersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
e p is' n o TITLL 5 the State Sanitary Code— The undersigned further agrees not to place the system in
o i'o a� r ca f Compliance has been issued by the board of Health. t
S-
igned---...----•- _;` `
....... ..................... P ......:._....--
ic 'on Approved B - r! �'."-- ? e
Date
plication Disapproved for the following reasons:................................................................................................................
------------------------------------------------------------ � ---••----r- .........................AOL
Permit No.---_•• ------•. ••--•_.t.. ?.................. Issued.........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
...............:..........................OF........................................................................
(In if irat a of Totnpliatta .
THR S TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
��-
- Installer #k
at------ �. .� .-- nck(-: ......... a ' t
has been installed in accordance with the provisions of TITLE j of The State Sanitary Caode as described in the
application for Disposal Works Construction Permit No------ ......... date( _...._`:..`
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A GUARANTEE THAT THE -
SYSTE WL" FUNCTION SATISFACTORY.
t.
a e ........................•---•--•-------...... Inspector--...... t ; ....................................................
DAT ...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f] 1 ............................OF.....................................................................................
, tea
No....................:.... FEE... ...............
Permissionis hereby granted---------------- -------------.......... ---•-------•------...------------------.......---........................._....
to Construct ( or d�eRair ( ) an Individ al Sewage-isposal Syst /l
1--z� -' "
at No. � =tt1CC,..: sn .................. ----------------- h.. .L-----=......----..._------------------.............
Street
as shown on the application for Disposal Works Construction Permit No.. .-_....Dated.._..` �� . .•,-.-....
/,oOf1//
DATE. �`.G S Board of Health x t
........................... ............_........................._ 3 W,#rvY:
FORM 1255 A. M. SULKIN, INC., BOSTON
w�5
— DF-- SIGKJ DATA
;ttJGLC FAMIt_�( - .�'� gEOROOM Q -7 Sao BIZ
:)iatL%( FLOW 110 X 3 = 730G.Pv N (ST-tZ
SEPT1G TAtJK = 330xl5o% ',49/6.P.
USE- 1 000 GAL. 4- T14
015Po5At_ PIT V51: t000 GAL.
- 5t,SSA X z ca FD , W F�I. r
50TTOM AR6.A= , So 5.F-,
'ToTA%- Ds-51614 = 42-r G.P
'T<)TAL DA 1 LY PLOW 33o G,PO N IC�,pv
f E2GOLATtou RATe: V i' j ZMW oti`Llr=55
C 3 o-z
OF 4,4.
OF �.�° .. ..PtTER ti�N
�Nlh. o . SUCLIVAN
RICHARD 0.
Z A. «�' No. 29733
.. BAXTER rn .0 p�
�No.240480
�Q R� s'16NAtEG� , . .
/STS dQ'
T6�T n 245o T o P F N D=
too INv.
�t13�ioIL DIST. INS• GAL.
t 060 l�V� .:,6PTIG S4'% .
INY, 5'4�L �rAutt
17A0D/ LEAGl1
4 - I
' t
WASK&D
SAIJb
GE2TIFta0 PI_07 PLAID
PRvFILG
s3� 13 NO 5GA.LE ScAi_tr
GE:RTIFK -CHAT 'THE t--VOMVNT1ot-' 5uoww PLAN REF 62EN GE
Kt-P—SO 1 GOMPL% 6 WITWTHE• S I OEL1W r--
ANo-SE-tt�.GK 2 a�1R.>✓M>=.N`I'� XT-
DA-T
-T">WN OPI `BArZ iT-AGUZAv IS,LOGp.TED •WITNItJ TN�6 G.�.00D PL�.IN
E -'�s=�� ( OMML/r
' 6A-K- G z e wm- INC.
�E6 I VT 1✓ZGT)'L A1.1 IJ 5 u?-w EYb?--Nob?
'Ting Ptr�N t5 MOT 4n5r-n nw aN o6TE2YILLE - MA66.
,� 11J5TR.uMENT SvQyt�`( �"TNE �I=�'S�'T'S SUau�,p
3/19/2020 ShowAsbuilt(1700X2800)
+41 9LEy Z-
LO CAT 10 SE SEWAGE ERMIT NO.
3
VILLAGE
,.I.NS LLER'S NAME • ADDRE LS
�IUILDER on OMINER
DATE PERMIT ISSUED z, c
DATE COMPLIANCE ISSUED S
3 /o' toy
..�w.d
i
https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=171176&sq=1 1/1