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Home My WebLink About0412 PRINCE HINCKLEY ROAD - Health 412 PRINCE HINCKLEY ROAD, C'VILLE A= 170162 I LOC A&'10 H --___. SEWAGE PERMIT NO. 2 , VILLAGE INSTALLER'S 4 NAME i ADDRESS r BUILDER OR OWNER ze l DA T E P ERMIT ISSU E D _3-��l DATE COMPLIANCE ISSUED �q re e ,�, C)o s..Fle ...::...:`�..........._. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH : .✓..�....................OF...........��...f .. .t Applirati.on for Uhipati al Workii Tnnitrnrtilan runtit Application is hereby made for a Permit to Construct (✓) or Repair ( } an Individual Sewage Disposal System at: Location.Add forNo.�b �1.1JA1 eNtL-9S LA 6,eAJ �VL(,L_6..A4�-........--•-•--•----••.....-• j -•-----•-••- ..........-.........................- It wnr Address - ............•---•----•-------•-- ....--..Address d Type of Building Size Lot________..r_________________Sq..'feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder. ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ................•-•----•------•- . W Design Flow........ .............................gallons per person per day. Total daily flow_______--••-rJ ................gallons. WSeptic Tank—Liquid capacity..teP.9.gallons Length5'f?.... Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length................_--- Total leaching area____-__.---_------sq. ft. Seepage Pit No--------.._l.......... Diameter....__�._______ Depth below inlet...... ...._..._. Total leaching area.Z.�?Isq. ft. Z Other Distribution box (�) Dosing tank ( ) Percolation Test Result Performed by.. "1 c_` _..lV .......................... Date-----(.0 ....... Test Pit No. 1.._.___Z-._.minutes per inch Depth of Test Pit-----t__1T........ Depth to ground water____��l��_.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .........,.............................................................................................................................--••---•-••---...----- Description of Soil ?--------1,-DAM.--- v 13 5... IL,f_.•--2-.._-•�- -- A n?D 6,.:_� Cl..f- v ......................�']�•---•------.1.�!t.-- P........................... ......................................................... UNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------................................. •-----------------------------------------------•-------•--•------------------------.........----••-----...-•---------------------------------------------------------------------------------........_. Agreement: The undersigned agrees to install the aforedescrib d Individual Sewage DisVrees stem in accordance with the provisions of iITI.L 5 of the State San4bee de The under ' ed further of to place the system in operation until a Certificate of Compliance hued he ar th.Signe / �--- ..--- _ Date Application Approved By--••-- -c`' ._... Date Application Disapproved for the following reasons---------------------------------------------------------------•----------------------------• .................. --------------------------------------•--••--•--...•------•---•-------•••••---•---•--........-------•-••------------•-•-----•-•-•----------•-------•---•----------------------------•--••------....-••-- Date PermitNo.....�N......................................... Issued--•-----------------------•--------- � ' ---------------•--- Date Fps.... > ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Lac ✓i11_ ....--. . .....OF.......... .2 S _ Appliration for Bi_qpoiial Worka Tomitrurtiutt ran it Application is hereby made for a Permit to Construct (r ) or Repair ( ) an Individual Sewage Disposal System at: C-�(Z 1 ................_ N t� JI-A Ni- G K ( 1 %)1N oi 2v...►..L..t.-.-..--- --------------•----------------. L Addrs �J �L 0- ---------- ------------------------- ------------------ =- = ---------------.. iGnu LA , rL_LC....... LA 40, a ........ Owner Address W Installer Address I U Type of Building Size Lot...l jt.G'UD Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Othgr-fixtures ...-•••••------------•-•••-••---- - WW Deign Flow.......q`-- __gallons per personper day. Total daily flow............................................gallons, L --___-_ ._._. ...G_ . _ 0SePtic Tank— iuid caPacit.._A..G...gallons Lenth ____________ Width................ Diameter__._____..__. . Depth................ f x Disposal Trench—No .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.........I-...-_..j_ Diameter.._...! .___-___ Depth below .......... Total Total leaching areal G':vsq. ft. Z Other Distribution box Dosin tank ( Percolation Test Results Performed b t\�"��- `' N 1: r Date....�.......... ..�_G _-__.... Y-- • ---• ----- Test Pit No. 1________________minutes per inch Depth of Test Pit----- ??-.-_____- Depth to ground water... lug Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ D Description of Soil.....J z L U A M ` 2 U 13 5 L-' 1 L- 2 .L_ ? S A+V D Y (, (? A te&L_ r ••-•-•••------- ----------------------------1------------------------------------------------------------------------------+�--- x •••-••----�-----��--------------�' �� s �P------------------------ VW -----------------------------------------------------------------------------------------------------------------------------------------------•-••---•---------------------•-----••-•--------•----•--. Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ -------------------- --------------------------------------•------------------------....----.........---••---------------------------------------------•--------------------------------.._.._........-- Agreement: The undersigned agrees to install the aforedescr' ed Individu Sewage Dis 6sal'NSystem in accordance with f't !'1' the provisions of ; 5 of the State Sanitary Co e— e un er ' rther agree not to place the system in o T t_,peration until a Certificate of Compliance has n iss by t zealt Igne .......•-•--••---- ------_..... Application Approved By...........`. Date '�APplication'Disapproved for the following reasons:-•--------•---•--•----------------------•-------....-------------••----•-•----------------------•-...._-•----... t- ----------------------------------------wt.-.:sa - .................................. .................................................................................................... Date PermitNo..................... -------- Issued-..-------•----...-----------------------------•......-- f e Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......... ........................................... Trrfif iratr of Tnrmpliana THIS?ZI Rk� That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.............................................................................................--------•----------.._.-----:........................................................................... �. ' Installer has been installed in accordance with the pro ' ' ns of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated-------------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL -FUNCTION rATISFACTORY. Inspector..............................................................DATE...... -------•-••..............;1: tn.11 .---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF....................................................... AQ. Nv ........................ FEE'�X. '................... Perr�aists o reby granted.............................................................................................................................................. to Constr ct or Repa• ( ) an Individual Sewage Disposal System at No.-------- 36'{....._�l.!n't ._. i n 1 . R K._ 6 1L?�3� ' Street i as shown on the application for Disposal Works Construction Permit, No..................... Dated.......................................... - --• Board of Health DATE------------------------------------------•-............ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS , SITE PLAN sHcEr I of z SCALE: at' VJ Ire--b,lLkA, lrl �, l0,00 Cob.Ir, h Irf°T Ic- 7'ArJ YC N Iq 14 .9z a 4 is .y4' 4 2 d4- l5� I r G I I� I tJ G P 1 r WILLIAM M. n WARWICKci 41 Y No, 19771 r Q 4 S 11 YPpYp1"Y[Am., FOR G�'. iZ L- 6'�2 l-L. 0 J REGISTERED LAND SURVEYOR �d 3 p rz I rJ L I-I I►J G IG L,✓�( V�p ZONED PLAN REF. DATE w� BENCH MARK DATUM z�M c� WM. M.. WARWICK 8 ASSOC., INC. DOMESTIC WATER .SOURCE Towti-► w*,e^^C� BOX 80/ - NOR TN FALMOVTN FLOOD ZONE. U Ll 0 &-L A-4 D �� MASS. 02536 - (6/7) 36J -26 38 LEACHING BASIN SECTION NOT TO SCALE of Z Y— — 24".C,l:MN COVER c EARTNFIL L BRICK AND MORTAR COURSES.AS REO'D• TO mlN6 ��.,, 'COVER rO CRADE NLE7 'FLOW LINE r. P':. "TO� WASHED PEASTONE FREE Of IRONS, PIPE •'; FINES ANP OUST.IN PLACE OPEN/NG W/TH 4%g". , •• S�4 N TD l%2"WASHED CRUSHED STONE. FREE or 7' (o� /BONS, FINES AND 'OUST /N PLACE OUTER 0/AMETEK ANO 13/4"INSIDE DIAMETER 1• CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6°x 6" NO. 6 GA. W.W.M. i 3. 2'AND 4' SECT(ONS ARE AVAILABLE FOR GREATER DEPTH REQUIREMENTS 4'04-- 2� --r- . s'O 4. NUMBER OF PITS REQUIRED) MIN. ( EFF CT/VE D/AM££R —1 NOTE: EXCAVATE TO ELEVATION 38 O OR (NOt rO EXCEED 3 TIMES EFFECT/VE DEPTH) LOWER AS REQUIRED TO REMOVE ALL �- WATER TABLE LOAM AND CLAY BENEATH PIT. REPLACE EXCAVATED MATERIAL WITH CLEAN TYPICAL PROF/LE GRAVEL. TO DESIGNED GRADE. 19"SrD. Lr. wGL C. All/COVER �.: 4°C.IPIPE 4"B/T.F/BER P/PE OUTLET LEVEL DWELL INS Ir FLOW_L T/6HT JO/NT INE TO FIRST✓O/NT r t� `4•, g �� o o I3 i 1 o 18 o 1 1 � i11op 00 111 � • 4q' gLfj p 'STD, PRECAST CONC. ' �}�.�'p 1ST. OX TO BE ' le 00 00 1 1 1 i GAL.SEPTIC TAN INS ALL DON LEVEL ' 11000 0 o a 1 , , — STABLE BASE ' t:1 10 0 00 0,I I 10p O01 1 i EPT/C to K TO BE O INST L LEvFc, i 1 10 l o 0 .1 0 ' i STABLE BASE, i 11000 00 0 1 + i1too OOII „ LEACHING BASIN : , i 0 0 p 0 0 0 0 1 i , BASE TO BE LEVEL. + + 1 8 p 1 1 �(,1;✓. SO/L AND PERC. DATA u TEST PIT NO. 1 TEST PIT NO. 2 PERC. RATE � G � MIN, /IN, 0 ' O ►° 1��iV/3'Jotl� TEST BY : IPX11 Trcl' IJYIr Z WITNESSED. BY: J . A Go w I G, hArvn�( u �1=L TEST PIT GR, EL, 2` 7 Mriv• 1-�v DATE I v- - 4��' I� r✓��V. N, o, G.Iz 0 D• w A Z 0�- 7 DESIGN DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL 00 SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL.330GP0• PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK GAL, ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL AREA? 20 GAL./SQ.FT, MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA ( � GAL./SQ,FT, SANITARY. SEWAGE EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIREDLZLI SQ.FT.. ANY -CHANGES TO T141S PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING APEA OF HEALTH. Q;FT. ''. ' �;;.AT ,COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/41 / FT, UNLESS INDICATED OTHERWISE. `"° � SEWAGf DISPOSAL SYSTEM MARTIN �o E. F G p Cz-,L v L-'L-v MORAN a, L.O T -j o'4' I7 r #23417dq l L. LL T- ,. .M � ,5�'�OlaA1.ENG _ SCALE O.S INDICATED DATE WM. M. #4RWICK @ A$50C., /NC. ®OX�, OI 0R H fA.4G00UrH NABS MOM PROFESSIONAL ENG/VEER 9 COMMONWEALTH OF MASSACHUSETTS v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI P n��IfVA s DEPARTMENT OF ENVIRONMENTAL PROTEC N 1 8 1998 ,w ONE WINTER STREET.*BOSTON. MA 02108 617-292-5500 N �y SV,y 4* WILLIAM F.WELD E T COXE Governor Dorothy Mailhiot Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner ^0 1(� PARTA f W CERTIFICATION Property Address: 4.12 Prince Hinckley Rd.. Address of Owner: l o < ^ Date of Inspection: ' _ I .c�l Centerville , MA (If different) Name of Inspector: WM E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: WM E Robinson Septic Servi Mailing Address: PO BOX 1089 , Cent ervi 1 1 Pr MA 02e32 Telephone Number, 5 0 8 7 7 5—R 7 7 F 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: 1/Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: A ) h Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original.should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indi to yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pigs 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep Printed on Recycled Paper l / s ,�� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T PART A CERTIFICATION (continued) Propeity Address:, 412 Prince Hinckley Rd.. , Centerville , MA 02632 ` Owner: Ddrothy Mailhiot Date of Inspecti6n: /;L—a,(„ei BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a 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 levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl URTHER 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. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 412 Prince Hinckley Rd . , Centerville , MA 02632 Owner: Dorothy MAilhiot. Date of Inspection: D] SY TEM FAILS: You m t indicate ei;?rer "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct th failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LAR E SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The wner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program re irements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 412 Prince Hinckley Rd.. , Centerville , MA 02632 Owner: Dorothy Mailhiot Date of Inspection: /;t Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks 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. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 412 Prince Hinckley Rd.. , Centerville , MA 02632 Owner: Dorothy Mailhiot Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:.334) g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):Z—o Laundry connected to system (yes or no): �5 Seasonal use (yes or no): A.-0 Water meter readings, if available (last two (2) year usage (gpd): 1996 50, 000 gal Sump Pump (yes or no): !L d ,000 ga 1998 22,000 gal (6 mos) Last date of occupancy: lJ-� i• COMMERCIAUI N D USTRIAL: Type f establishment: Design low: gallons/day Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water I eter readings, if available: Last d to of occupancy: OT ER: (Describe) Last e of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pu ped as part of inspection: (yes or no)—Z-� If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 17 Sewage odors detected when arriving at the site: (yes or no)-/,,- CJ (revised 04/25/97) Page 5 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4.12 Prince Hinckley Rd., Centerville , MA 02632 Dorothy Mailhiot Owner: Date of Inspection: i BUI LNG SEWER: (Local on site plan) Depth low grade: Material of construction: _cast iron _40 PVC_other (explain) Distan from private water supply well or suction line Diame er Com ents: (condition of joints, venting,'evidence of leakage,•etc.) SEPTIC TANK:`V (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 Certificate of Compliance _(Yes/No) 0 ,1 Dimensions: Sludge depth: Distance from top of sludge to�bottom of outlet tee or baffle: Scum thickness: L " Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: l l� How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or�affles epth of liquid level in relation to outletinvert,, structural integrity, evidence of leakage, etc.) lr �-- c�b/� ti. ��' es GREASE P: (locate on ite plan) Depth belo grade: Material of onstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimension : Scum thic ess: Distance,f om top of scum to top of outlet tee or baffle: Distance rom bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comment (recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (revised 04/25/97) Page 6 of 10 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -Property Address: 412 Prince Hinckley Rd,.,,, Centerville , MA 02632 Owner: Dorothy Mailhiot Date of Inspection: . TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locayitelanite plan) Depw grade: Mateconstruction: _concrete_metal _Fiberglass _Polyethylene —other(explain) Dim :Capagallons Desi : gallons/day Alar : Alarm in working order Yes; No Dateious pumping: Com(conf inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Z Comments: (note if level and distribution is equal, evid nce of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms ii working order (Yes or No) Commen s (note cor clition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 412 Prince Hinckley Rd- , Centerville , MA 02632 Owner: Dorothy Mailhnt Date of Inspection:> �L-.4-/-5 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note ondition of soil, signs of hydr is failure, level of ponding, condition of ve etation, ) Fr zA-) v rt 7L-- 12 CESSP OLS: _ (locate site plan) Number nd configuration: Depth-top of liquid to inlet invert: Depth of olids layer: Depth of cum layer: Dimensio s of cesspool: Materials f construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents: (not 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 Comme ts: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (rev' .d 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4.12 Prince Hinckley Rd.. , Centerville , MA 02632, Owner: Dorothy Mailhiot Date of Inspection: lo2_el -0, 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) CM V Y y (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 412 Prince Hin.ckl'ey Rd.. ., , Centerville , MA 02632. Owner: Dorothy Mailhiot Date of Inspection: Depth to Groundwater I Feet 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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) /7 k l9 j r=o•ZC>�."��.�/q 6 (revised 04/25/97) ?age 10 of 10