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0493 PRINCE HINCKLEY ROAD - Health
49=PINCE HINCKLEY RD, CENTERVIL3 R A 107 213 A lid No....`.�. � l . Fps... ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEP�TH lilt -..OF........ .............................. ....................... Appliration for Disposal Works Tont.rurtiun Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal syst AAA l=s 071-5 Kd e .. ... Ce c��cl��.:...... �............ - .. - -•---• -__...•-- ----- --•- _.... --- - gbpWtion- dress or No.------- O • Address w a .......... - -----------1------1------------ 1-1----1- , "�... Installer Address tt d Type of Building Size Lot.0 ,A...�____Sq. feet aDwelling—No. of Bedrooms_______________ 0_ .----------------------Expansion Attic Garbage Grinder (/t#o p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) p" Other r ._._. W Design Flow__________ _________ _____ __________gallons per person per day. Total daily flow._____________ ©......___gallons. WSeptic Tank—Liquid capacityl allons Length................ Width................ Diameter-________-______ Depth................ x Disposal Trench—No_____________________ Width...._.``.____________ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--.I,. Diameter.............h!0__ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------••----------•--------....__.......__._..._._.....-•-•-----•----------•--•--•----•---•-----•--•.....__..............-----•-- 0 Description of Soil...........................-•-•----------......_._...--------------------••---------------------------------------------------------------------------------------•---- x U -----------------------•-------------------------------•-------•---------------- W -•-----•---------------------------•----•---•-------•-------------------•----•--------------•-------------------------------------•----------•------••-----••----•----••-•--•-•-------------•.......---- UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th provisions i f the State Sanitary Code— The undersigned f ther agrees not to Vlaceeyste in atio nt' a ifi f Compliance has been by the b of lth. tned_ ____________g -• -•---_-•_.. e ica,tion Approved By------•-•-•------•-•- Da pplieation Disapproved for the f ollo g reasons: ----•--.......---•-- -------------------- ____ -----------------------------------•----•---Date-----••-•-..._ Permit No-------------------------------------------------------•- Issued_...................................................... i ------•-----._...-_ _..... Date No................-.....-- 'r Fms........... •-••-...... THE COMMONWEALTH OF MASSACHUSETTS x BOARD OF HEALTH ........................................:.... .................O F..........................------.......--------------------......._....................... .XvPfutttuan for Mgpaaa al Works To atrl fion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at TAMES pT1,5 Rd, ---= -----•-- ------••- -------------------------•--- .... Location-Address or Lot No. �,. ......................—. . A ............................... Owner Address a -•-•........'-•-•..__......••-••-•-••-••--•--••-•••.........................•--•-•------•--•--••-. ... Installer Address U Type of Building Size Lot.,. *.'_......................Sq. feet w. . Dwelling—No. of Bedrooms............................................Expansion Attic ( £s) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons........................... Showers ( ) — Cafeteria ( ) Other fixtures d -------------------•----...........--•-••....... W Design Flow...............::..........................gallons per perso pe ay. Total daily flow__._____._............................................ ..gallons. 1:4 Septic Tank—Liquid capacity...2........gallons L6—gtk................ 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 ( ) aPercolation Test Results Performed by....... ----•--•------••-•••-••••......-•---•••-••.........•---•---------• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •-••-•••--•-------------•---•--•.............---••-••-••-••••----•--•-••••------•--••--......----••.......................................................... 0 Description of Soil.............................................•-•------------•----•-----••-•--------------------------------------------•-----------•------------------•-••-•------.•••-- x U .............................--•-•--•••••---•••••------•••••-•-••-•-•-•....•••-•--•-....................-•-••••-•-•---•---•-----•-•••--••••---•••---•--•--••••--•••-•-••••-•-•••-•--------••......•-•-- W 4. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..._............................................................................................ ---------------------------------•---•---------------------------------•-----------------••-----------............-------------------------------------•--------------------------------...••--•-..--•-- A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th provisions T of the State Sanitary Code— The undersigned further agrees not to place the system in eratio unt' a , Iifi t f Compliance has been issued by the board of health. igned......-••.......... •........--• := ' at p is ion Approved By...... ......_.... > .. � a e pPlication Disapproved for the f ollo g reasons-----------------------------•---------------------------------•-------------------------------------------•---- --•-------•---•.............•--•-•-----............---------...-------------------------•---•------•-----._.....--•------•----------------------...-------------•--------------------------•••--••------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... (Irdifiratr of Taatnpliattarr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) br..'0�: ........J.�.........................................................................................•--- y----------------------------------------•-•--• ? Inst I r has been installed in accordance with the provisions of TITIE_6f Thee, State Sanitary Cod , 1 s ribed in the application for Disposal Works Construction Permit No_______________________':_.._._!_q.... date d_._.___:__-��_.g_ ._ 4_................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARttttAN EE THAT THE SYSTEM IL FUNCTION SATISFACTORY. �t DATE........Y/..Iz � ................................................ Inspector---•- •--------------------.._................-••----•••--......._---•••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... F0...�"�................... Eiopoal Work.5 Taantrnartiaatt ra�int't Permission is hereby granted.................R.Qb:e'-'. .......-r-�' _U_1 k to Construct (yf) or Repair ( )- �,n Individual Sewage Disposal System J' c t at No---------- -------------------- r, .. �.l.N Street _ ... .�. = ` �G �� l as shown on the application for Disposal Works Construction Permit No:._-�__`_ _!`Dated.__. .3_. .��'.1- ,--••............... ...................... `.1 -----................................... Board of ealth DATE...Ov.V&_-l .F FORM 1255 A. M. SULKIN, INC., BOSTON V { DES IC N DANTf-\ A%ti ti 5.I NGLE FAM►11j 3 F3CD l2•n o I`'� P� (c CQ. i No GF��2.l3ACsE G121N.DCCL. �� ) Y OVA It%J Fk-ov,/ 1 o x 3 m 35o G.P t�. O,(•`' ,Ip �� i 5EPT1 C. :TANle- = 3 3 So'o 49S G.P. D• VSE lovo GAL. TAKW., DISPOSAL Prr ^- v5E 0) ' torso GAL. %z'- SI DEWAUL A2.EA s s �sT�as- �So , F s,F 2 x o a 1 So .S 37ar'. Cr-:P.O. `, 'Fw►.�'D�►T� To-rA l bESIGN 4ZS G. P. D. P T.TAL UAIL.Y FLovV - SSO G-. P. D. : qs TioN R.AT� ; I,,iN Z M,� .otL UESSOF o PETER Ian,N �. O SULLIVA 'y. ��' R9CFiARD No. 29733 A a. BAXTER 140" �C�s re�(� No.240,48 � ,40 1 1 , T TEST 5725 Ct_: -G S2 't �•. �: b�R.So`l. /coo DisT. /0,00 /� :•.,. /N✓. GAL, :' S"��,' 50 GAL BoX �P r 4 e7 49•°3 G'E.2T/F/Eo PG OT L:Q . : WRsHC-D :• P N ,5LA= sr N E .,a V �, G•• I, ,E 43 ,s : LCG,GT�o si CE�u R-!L v i LLES p_ Are PRO F'l LC MO SCALEp ?Nr4rT.y� F �voRT'a� S.yaw.v i-/16A(4AvoS .diVO.SETI3/JG� ,eE4V/,eEHI�//TS'd,a 7M4 �2.E6isr�,ec�.t-Q.vo.slieyEYo,�S j :ToW.v of [3�tt�+J STac•�l;, .av� /.savor- �.sr�.eYic� o- .�as.� G T7y.E' ,�LaoppG.4/�V ,A.�.Cic•4,y/-- A t-,q A l SmACG LAG. i � � T//!t 13As�o oAv.Q�V -d�fE�Yr-.Sve`•cyA�vO THE o�FS,�� o o - a,, LOCATION EWAQE PERMIT NO. � n PtlAc��hcko-y G VILLAGE 3 , INSTALLER'S NAME&ADDRESS co BUILDER OR OWNER �6 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r �+: ��cK .. ��� 3`! Y ¢_``' r. V—ATa0 SLi GF € RMiT �! }. VILLAOL IHSTA LL " R'S HAMS A D 0 R E S S 3 u t L D R GR- 0VVYH ER DATE PERMIT ISSUED t°C-i�g 361 fat 3�t Xc p TOWN OF BARNSTABLE LOCATION `�;h C-- «i 1<-.7 SEWAGE# VILLAGE ASSESSOR'S MAP&LOT G—al-3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /o O o ( . LEACHING FACILITY: (type) • (size) (.X - NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t JAC Sfi cp , o /A-s���,I � �� lam . — I-70 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COP WU - _ = COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION y93 P;—.,,�� ff;oic-k /e ►2,4. �/�•� Sfa�le s Property address: Y Name of owner o vl�)�� C c.r +c,- (I c Address of owner- I/9 3 Pi-,-.,c t 141 n Date of 3/ S /0 0 Name of Inspector:(PleasePrint) liamc LLCc.n tr✓ �c� /Na U tG Tm�Wil I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy Williame Sn titer Insnaebons Mailing Address: 19 Hummel Drive So. Dennis, MA 02660 Telephone Number: (508) 385-1300 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: V Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspectors Signature: Jay, it��,�,,,Q Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS l L- 1 1"C revised 9/9 /oa ,.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contnued) o�Y A�feu' 493 Prince Hincley Road, Centerville, MA Date of kupection: Donald Stables March 15, 2000 INSPECTION SUMMARY: Check A, B, C, or D: A. /SYSTEM PASSES: V 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15,303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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). 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 revised 9/2/98 Page 2orII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 493 Prince Hincley Road, Centerville, MA QWt1e•: Donald Stables Data of I"spection: March 15, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: "J/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the Public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH.DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING W 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 of 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 9/2/98 Page 3o(11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 493 Prince Hincley Road, Centerville, MA Property Address: Donald Stables Owner: March 15, 2000 Date of Inspection: D. SYSTEM FAILS:/t//`9 You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage 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 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: A114 You must indicate either"Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of I 1 a. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST P-Perty Address: 493 Prince Hincley Road, Centerville, MA Owner: Donald Stables Date of Inspecoor,: March 15, 2000 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 rorrnel 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. Y _ 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. �L _ 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: Existing information. For example, Plan at B.O.H. i — 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)) �- _ The facility owner(and occupants,if different from owner) were.provided with information on the. Subsurface Disposal Systems. prnpermaintenaaceof revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owrw: 493 Prince Hincley Road, Centerville, MA Date of Inspection: Donald Stables March 15, 2000 FLOW CONDITIONSRESIDENTIAL: Design flow: I 1 U g.p.d./bedroom. Number of bedrooms(design): •3 Number of bedrooms(actual):-; Total DESIGN flow :3 30 Number of current residents: 3 Garbage grinder(yes or no):—!1�S Laundry(separate system) (yes or no):-&O: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):/VD Water meter readings,if available(last two year's usage(gpd): 1�`Iy�c�c u/lp�, S S g= /S B pv p y4/���. S. Sump Pump(yes or no):A Last date of occupancy: j0+ r- . COMMERCIAL/INDUSTRIAL: /VIA . Type of establishment: Design flow, qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:(yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: C System pumped as part of Uon: (yes or no) .Vv If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _V 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.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed W known)and source of information: N 1 (.} i h Sewage odors detected when arriving at the site: (yes or no) A/d revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 493 Prince Hincley Road, Centerville, MA Date of Inspection: Donald Stables BUILDING SEWER: March 15, 2000 (Locate on site plan) Depth below grade: Material of construction:_cast iron__,,/40 PVC other(explain) I !�J Distance from�pnvate water supply well or suction line Diameter I/" Comments: (condition of joints, //venting, evidence of leakage,etc.) -/91( l r1Gf WC.r L. '7?jiln!/ C (L tr T rr.t CST U ._.. . SEPTIC TANK: (locate on site plan) i Depth below grade: � Material of constructi n: ✓cooncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: S .� 9 �X G ' /v o d y cc//o Sludge depth: . .'� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness-7t„ j oar.,r Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Pry 6 e Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structur tegrity, evidence of leakage,etc.) (.Uh�r� �« 1�'r o �/ f- .u„ go r GREASE TRAP: /✓ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7ofIt • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Owner:Property Address: 493 Prince Hincley Road, Centerville, MA Date of Inspection: Donald Stables March 15, 2000 TIGHT OR HOLDING TANK:_(Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: ./ (locate on site plan) Depth of liquid level above outlet invert: Comments: (no .if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) —;7d IK L—J-,A l PUMP CHAMBER: 10 (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8 0(11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 493 Prince Hincley Road, Centerville, MA Date of Inspection: Donald Stables March 15, 2000 SOIL ABSORPTION SYSTEM(SAS):7 (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: O h m 6 X C b—i, P „✓ ► S�z•H leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) w e- + CESSPOOLS:_M 9 (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of.hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:LV//9 (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.) • revised 9/2/98 Page 9orIi • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner= 493 Prince Hincley Road, Centerville,MA Date of Inspection: Donald Stables March 15, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I w3 35 J p Q°x P ' revised 9/2/98 Page 10ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Owrw: Address' 493 Prince Hincle Road, Centerville MA owner: Y > Date of Inspection: Donald Stables March 15, 2000 NRCS Report name Al�/a Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater&Feet Please indicate all the methods used to determine High Groundwater Elevation: V/ Obtained from Design Plans on record Observed Site lAbutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you establisheed�the High Groundwater Elevation.(Must be completed) Vh� y irtc� �GS A 'let rt �orOt c � Oti �� h 0 In \ F U-4 A- t-to 2 S�, W1a f t yi-p ✓ no/ Wo 4w✓ Gl f OVt✓ • revised 9/2/98 Page 11 of 11 DESIC-N D/�T/-\ rl 5 I NGLE FAM I UJ Q� v ff I/ No AIZ GAGE G121tJ DC(Z, i ,1! � DA I LY F Uav,/ I I o n 3 33 o G.P. V. ,(.`' : ,gyp `�� Ilk u SEFTI C TA N Ic. L 3 3 o x I So'o - ¢q s G.P• p, ` 0 0• USE l 000 GAS,. T NW. D►SPoSgf_ vsc W j000 GAk- 5i DCwAL- - A rzCA �� I So 6.F z ,S = 37S � Fov�.>OATI o►J BoT'oM AREA = 6o So S.F. x 1, o Sty G. P, D. �� a �► ToT"N 1, OESIG&J _ 425' G. P. D. �i ►`• -PTAL to iLy F-LovJ G•, P. O _ 3 3 o . o vT TI olv Q.Al- 1''I N Z 1 � �,� \ MAN ,02 LE M , ;oo • q'TM ' o o ti �y (_oT.b o� S P VAN G�`" .�•!��r`tN o Ariss�G► LuT I o ' �v� "IV Yids I '1 RICHARD No. 29133BAX STGn� No. 'E O T'EsT' Hole F- 672-5 6A 4--rr✓rt.. 4 �j� z�c .t=L..52-' Loam .. /coo Disr.' l�srEv.S�� /Odp / � � t•', /.f�✓. 2 60 Gq l� / Box /v✓. G.4L• Cegc.N 3 sE'Prrc o CLr .�l . Ps7T ' q9,f o� 0 f TANS 49►7 . : W R s H C-D :• G',�`.2r/F/E.o PG OT pL;gi✓ .* ST AJ E ,b _ L VE •(3,5 LoG.��7'oH CE�17Z2ViC�,� PKOF�l LE /10 TN,4T 7'//E /-auAuOq 7iat> {....C'r✓�v I ,v i(( 14 i6'ilA AJ o S .YE,�Eov • SHcw.v cOr►IOLY�S W/TX/T�,��'S/.oB'/.,/.�tl�' BdXT�,e A�V�.f�7r'l�AG.e .2�'4V/,e�N1�Nr.S o.� TiyL: I've. f�Nye; i2E6�.f� � .P.E!> �tNO.S!/,eYsS C3AR•►J STAC3U:, ,Q,v�/,S.vor- 7ylt P4rti /.� �07"�l3AlEp GN,Q/!/�Y.fT,�Z-- d'q,C/O-- ve�/EYi4�t/O.TX�E o.�FS.� S'Sd lyit/f/�6��'.S.w�ct/G p�/ar pte USE' ------------ TROY WILLIAMS r No SEPTIC INSPECTIONS , nI jq Certified by MA Department of Environmental Protection S (508) 760-1819 V o 40 Old Bass River Road y ' qp South Dennis,MA 02660 $ Comrnonweatth Of Massactxuetts ExeC-OW Office of EMOrmentd Affdfs (COPY Department of• Environmental Protection %VMm F.Wald riorunW Trudy t`,oltrl Drtvld IL trtitma SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /" l�/y 3 pj i n z .lj/n /� � Rd. Address of Owner. Nature of I I l y Seofinspection: l Of different) Company Name,Address elephone Number: S C,bC, c 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: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature. Date: The System Inspector shall submit a c of this inspection report to the Approving Authority within thirty(30)days of conmpleting this inspection. If the system is a shared system or has a design flow of 10,000 go 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, 8, C,or D: Al SYSTEM PASSES: y/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. 81 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'rot determined', explain why no0 The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfihraion, 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. (r"i•ed 4/1S/9S) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 419,3 Owner: j-1y H to) Date of Inspection: 61 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): 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 C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water _. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank ano sou absorption system and 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 is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 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. revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1' CERTIFICATION (continued) Property Address: 1 p 3 � Owner: ���h y Date of Inspection: DI SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged 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] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the Iota( regional office of the Department for further information. (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 3 I�r-' <e- /Kt"IL/cy Owner: F4, h Date of Inspection: Check'if the following have been done: Pumping information was requested of the owner, occupant, and 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 WA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow _ZThe site was inspected for signs of breakout. 11_/All system components, excluding the Soil Absorption System, have been located on the site. ZThe 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. _ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owe, (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: y P''' Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 33a eallons Number of bedrooms: 3 Number of current residents: oT Garbage grinder(yes or no):_&o Laundry connected to system (yes or no): vas Seasonal use (yes or no): n/a Water meter readings, if available:_ 7_/6�. Last date of occupancy:_QLvy� . COMMERCIAUINDUSTRIAL: A/1/4 Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ,>,,� AcJ�y : Fv o b{u z o..J -.s✓ System pumped as pan of inspection: (yes or no) If yes, volume pumfled. Qallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information:, c l S Sewage odors detected when arriving at the site: (yes or no) IV' (revised 8/15/951 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: y SEPTIC TANK:_✓ (locate on site plan) Depth below grade: /8'" Material of construction: ✓concrete _metal _FRP —other(explain) Dimensions:_ Sludge depth: Distance from top oTf sludge to bottom of outlet tee or baffle: e12 Scum thickness: -�-% /mac c �• i Distance from top of scum to op of outlet tee or baffle: / Distance from bottom of scum to bottom of outlet tee or baffle: 14LI � Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) � Mil ✓c ram'/� �� �-�— ; �., s C> 4'1 x Y a d rot t✓ � T � ,r— /6 4 �Ga S 6� ✓ �7 7/J �[i4� / Gi- H't �.it�i t .1 k of c►3 H o f i H /n ,c J T 015AJ = �2 :I �— - GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: >cum thickness: Distance from top of scum to top of outlet tee or baffle: 'distance from bottom ni crfpm fn hottnm of ouUe! tee or banie Comments: .recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) irevised 8/15/95) 6 1 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: TIGHT OR HOLDING TANK: ^111 (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate on site plan) Depth of liquid level above outlet invert: 6t/ c Comments: mote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) s k W A S %..0 t ✓ " ( G o G� PUMP CHAMBER:�i9 (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: y 9 3 /��•�,�c '�,� � Owner: F/ Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):y (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._z 0 t C 'k6 4 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) i � � ✓J« C 7L— CESSPOOLS: !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: ndication of groundwater: inflow (cesspool must be pumped as part of inspection) 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.) if I revised 8/15/95) 8 r . A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contlnuc4 Property Address: Owner: Date of Inspection: /7- SKETCH OF SEWAGE DISPOSAL SYSTEM; indude Ges to at least two permanent references landmarks or benchmarks locate all wells within 100' y3l ys TNT t,J / 'sto h c. _ DEPTH TO GROUNDWATER Depth to groundwater: — feet adjusted high groundwater level method of determination or approx tion: / Le-S A /,- ,,< - o -a <d o �o/I.., —� (revised 6/15/9S) 9 L 3�.52 y,,� ' 2�ti S I NG-LE' F-AM 1 L'i - 3 BCD kZo o rl P`7 \� (c c DA I L--Y F LovJ = Ito x 3 - 33 o G.P L>. SEPTI C. TA►Jle- = 3 3o n ISo', ` 49 S G,P. p• ` 0 USE 1000 CAL. TAQYL D►SPoSAL- 000 Cat,_ `z± s1C)CV AL- - ARLEA �jsr�a� �So s. F . 3 7S Cr P. CO). Fw 0t�AT�U►� Bo1Tom AP-CA = 5'o So T a-FA L bESIG►J = q 2S G. P. D. I '�z o$ � oT/AL_ l�IC� F�.ov\/ = 330 G-. P D. —fill- - / N Cq U-q a o t-3 P-A TE : l"i N ,Z M r n.1 . o a- LC s o �o Ill �w o AV PHER v LuT 10 i apy SULL!VAN fi1�,HARD ��'``< No. 2°733 � �l� 043 BAX ER Rix- -Fes-r HcLC P- 57Z5... 'SA L t�C 4� / coo /.v✓. G AZ-. Sn tzqC,N o• P,7- P 7.4/✓.L jrw i' /.v✓. /.cN W A s Hf`iD 4 �? 49• l'EST/F/EO PG OT pZ-4AI •f S7'c�J E ;a � ` J, c•�-{ ,--.E 43. L 0G,LT/O-11 R 2 V C�. �� �2 9• �o SCALC b.11J R Tt.'tZ ' CEeri,C-Y 7fr,4T 7hv '_��Coti G'O�Jf�GY,.S f•S//T��Ti`�E ,�/.OE/�/fJE � B,4X7c',2 €��(✓�E /.vG. ��`✓�.S�Tl�/3C/� ,�E4lJ/.eEti1ENrS Off' Th'F_ ,QEGisr�.erO.�-a�✓o sve✓Eyo,�S A Q-Q S TA�1�. ,t1.v1� /S NOT' ZICr 1-1 Zl/✓T- ,/j L q.j -Eric'. i - 7-, is .v /.s I'AlEp a iv .a IV,/�Y.ST,e-,57 i -�//fE�Y�.S✓,��f�G-y.�J�vO THE o�FS�.�